A revolutionary yet simple E&M coding system that will increase your income, reduce your time spent on documentation, and ensure coding compliance. So what do you get in
Dr. Dunaway's Documentation Success Package? Everything pictured here...and more!

A detailed description is provided below of all the Documentation Success components. The total package is a wealth of informative tools and even practical advice that is designed to help you get every penny of E&M reimbursement you deserve, save time by understanding exactly what must be documented, and to never fear a third party payer audit again. Best of all, it provides a training program so office staff can help you be even more efficient and profitable. In other words we are going to increase the market value of physician time.

BOOKS
Pocket Guide to Clinical Coding -- Dr. Dunaway's revolutionary approach to E&M documentation and coding excellence.
Risk Based Coding™ Manual -- A step-by-step guide to best use of the Pocket Guide, Flexform, and Coding Checkbook.
Doctors are from Jupiter: Compliance from a Galaxy Far...Far...Away-- Co-Authored with Joe Batte, CFI and written by Tom Criser to give a physician and a former OIG certified fraud investigators view of medical compliance.

CODING AIDS & TOOLS
These tools allow office employees to gather required documentation information using the Risk Based Coding™ System to increase efficiency of physician time and profitability.

Quick Inpatient E&M Reference with Specialty Exam -- A simplified Inpatient tool for physician or physician employee use.
Quick Outpatient E&M Reference with Specialty Exam -- A simplified Outpatient tool for physician or physician employee use.
BI -- A remarkable template designed to capture any inpatient admission, outpatient encounter, and any consultation that you may encounter using the Risk Based Coding™ methodology.
Coding Checkbook -- A wonderful recording and teaching tool to capture all inpatient follow-up visits accurately using the compliance correct Risk Based Coding™ methodology.

AUDIO LEARNING
2 CD Audio Program -- For ease of learning the theory and application from a live recording from a hands on physician program.

VIDEO LEARNING
Physician Documentation DVD Program -- A 90 minute visual experience designed to give you your own presentation by Dr. Dunaway similar to his hospital programs but devoted entirely to the use of the Risk Based Coding™ System.

BONUS!!
With this multimedia educational package you'll be given all the tools you need to create a physician friendly, documentation success program for your office. But to help you to take all this information and implement these concepts Dr. Dunaway will give you one-on-one, (or an office conference call with you and your staff), time with a personal 30 minute coaching session to customize his documentation system in your practice for maximum return on your investment.

ORDER TODAY!

Back to Top

A word of CAUTION!
It takes a lot of words and time to explain “how it works” but very little time to “use it.”

How long does it take a computer guy to explain “how the internet works?” But how long does it take to actually use the internet?

The Risk Based Coding™ System provides the key to open the lock, but we’ll explain how the lock works for those who are interested.

Traditionally, coders have us write down clinical notes and then deduce the appropriate code. In other words, we write a history and physical, and the CPT E&M code is derived from the documentation: (H&P --> CPT)

The Risk Based Coding™ System uses a CONTRARIAN approach.

By figuring out what the “correct” level of CPT E&M code should be for the patient encounter, a physician uses the rules to show them exactly what to document to pass an auditor’s inspection. (CPT --> H&P) This is not only easier, (because physicians don’t have to memorize or learn any coding knowledge), but it is more efficient. It also allows a non-expert coder (like us!) to get the expert correct code every time. It’s not that one way is “more accurate” than another; technically, it’s “right” either way and is perhaps better represented by (CPT <- -> H&P).

When we use MEDICAL DECISION MAKING as a catalyst, we can drive the equation CPT --> H&P, which also gives a higher product yield! Rather than learning complicated algorithms for each individual grouping of codes, one algorithm that converges on the proper E&M code is all that is necessary, saving time and frustration.

85% of all submitted CPT codes to third party payers are Evaluation and Management (E&M) codes. For most physicians, nurse practitioners, and physician assistants, that’s where the money is, day in and day out. Technically, non E&M CPT codes are pretty easy. Either you did the work for the code, often described in a single sentence, or you didn’t. And don’t get me wrong, there can be lots of confusion over which code is best (that’s why we have coders, because a good coder will pay for their own salary and still reap you dividends) But for E&M codes, there’s no way a single line can adequately describe hospital admission codes 99221, 99222, or 99223. It is of paramount importance to understand basic, everyday E&M CPT coding.

KEY E&M COMPONENTS
By understanding the key components of E&M coding, (History, Physical, and Medical Decision Making), and how to effectively use that knowledge, your E&M coding will be accurate and properly supported by better documentation. The important distinction is between using the E&M codes and understanding the codes.

If physicians know what to include by audit standards, the level of coding will be more precise and reimbursement will become more accurate. We’re familiar with H&Ps, but Medical Decision Making (MDM) is more mysterious. That’s where the understanding pays off.

MEDICAL DECISION MAKING (MDM)
MDM is a gestalt for most of us and few physicians are aware there are formalized criteria determining level of MDM published by Medicare. For physicians, components of MDM -- Risk, amount of Data, and number of Diagnoses and management options -- are not specified precisely the way an auditor would. Auditors formalize it. We typically include some of the MDM components by our routine documentation.

So why not use the rules to make sure the actual requirements are included? This algorithm is the basis for my success with E&M coding, as well as for thousands of other physicians who now use it daily.

1) Risk is formally assessed for a patient encounter using AMA/CMS guidelines. All patient encounters can be classified by four categories of risk as published by Medicare E/M rules, (ask your coder to show all of them to you). For me, reading these risk tables was an epiphany that allowed development of my Risk Based Coding™ System algorithm. Determinants of “high” risk are outlined with the clinical example.

2) Counting or numeric audit form generated checklists allow the physician to “score” the record before the auditor does using 1. amount/complexity of data to review/order and 2. number of diagnoses or management options to provide the remaining components for MDM. These checklists are used to grade the level of complexity of both Data and Diagnoses and involve assignment of numeric values 1 to 4 for each of these components.

There are a number of published references to these in coding manuals, instructional texts, and auditing resources and there are specific variations among these sources. By taking the MOST CONSERVATIVE values, we avoid compliance dilemmas.

3) Precise MDM is formalized by accurate Risk, Amount Complexity of Data, and Management/Diagnosis options determinations. The lower of the two highest categories of Risk, Data, and Diagnosis--determines the overall MDM with the aid of a simple table formulation we have all seen (and usually ignored!). The clarity of the system makes this table much less daunting.

4) Once the defined level of MDM is known, the correct CPT code to correlate with the MDM level can be determined. This is a “backwards” approach to the CPT codes listed in the front section of the AMA’s annual CPT guide. Nonetheless, this “backwards” approach is clinically more functional than traditional “coder” approaches to E&M coding and consistently yields the “expert” E&M code. This specific and correct code starts the medical record for billing ease.

The first detail documented is actually the precise E&M code. The system then assures all documentation required to support the code is documented -- all without specific “coding knowledge.”

5) Specific history and physical documentation guidelines for each E&M CPT code are determined because each specific E&M code has detailed requirements about level of overall MDM decision making, a level of history component, and a level of physical exam component. This specific information can be organized in a dictatable or written format.

The medical record now sustains correct reimbursement based on a MDM-driven CPT code assignment. Because the documentation supports the CPT code, audit risk is minimized. The accurate CPT code is on the medical record itself. There is no process breakdown between our work and services billed from the methodically derived CPT code and we are reimbursed fully for our work. Because the exact minimum of documentation requirements is known, volume of documentation may decrease overall.

MDM typically corresponds to the patient’s Risk assignment or at least gets you in the right ballpark. You must still qualify that same level established in Risk with either Data or Diagnoses categories to set the MDM level.

Because Risk is so important to understanding the process, here are the CMS determinants to HIGH level of Risk:

IF YOUR PATIENT HAS....

• One or more chronic illnesses with severe exacerbations, progression, or side effects of treatment
• Acute or chronic illnesses or injury that pose a threat to life or bodily function, e.g. multiple-trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self/others, peritonitis, acute renal failure
• An abrupt change in neurological status, e.g. seizure, TIA, weakness or sensory loss

IF YOU ARE GOING TO ORDER...

• Cardiovascular imaging studies with contrast with identified risk factors
• Cardiac electrophysiological tests
• Diagnostic endoscopies with identified risk factors
• Discography

IF THE PATIENT WILL NEED....

• Elective major surgery (open, percutaneous or endoscopic) with identified risk factors
• Emergency major surgery (open, percutaneous. or endoscopic)
• Parenteral controlled substances
• Drug therapy requiring intensive monitoring for toxicity
• Decision not to resuscitate or to de-escalate care because of poor prognosis*

By understanding how our most basic documentation is audited and subsequently evaluated for an appropriate code assignment, we will have opportunities for correct coding, typically accompanied by improved reimbursement because the system puts an end to the downcoding 90% of physicians (or their offices) habitually do.

How about a real application of how the Risk Based Coding™ System functionally operates?
This is the documentation of an actual patient I was asked to see on for a “r/o appendicitis” consult from a pediatrician when I was refining the algorithm. (All identification information has been deleted to maintain privacy.)

In brief, there are 7 steps to employ the Risk Based Coding™ System:

1. Identification of Patient Risk
2. Assignment of Data Points
3. Assignment of Diagnoses Points
4. Determination of Medical Decision Making
5. Selection of Compliance Correct E&M Code
6. Documentation of History Component and/or Physical Component
7. Documentation of How Medical Decision Making Was Formulated

The sequencing of the steps does not coincide with the actual documentation. Before anything is written down, the first five steps have been completed, because the first documentation point on the paperwork is the actual code.

Here it is, as reproduced for this webpage from the actual hospital transcript....

3 Words: IT... MAKES... SENSE!

IT'S ACCURATE
This documentation system uses the rules of third party payers and it’s 100% compliance correct to ensure that there is nothing illegal, immoral, or anything even vaguely resembling upcoding. The documentation supports a code that is justified by the medical decision making complexity of the patient. The physician is bulletproof to an auditor.

IT'S FAST
Granted, the explanation of “how it works” is tedious and lengthy. But it’s very fast in its application. Here’s a quick example of why this works fast: Patient presents to the office with a breast lump. RISK: moderate, new diagnosis with uncertain prognosis. Diagnosis: new diagnosis with workup planned. (even without DATA or ANY ADDITIONAL INFORMATION), the LEAST Medical Decision Making Decision level this could represent is MODERATE). If indeed it is Moderate MDM, an office visit of an established patient would translate to a 99214 and by the instructions, a Detailed level of History OR Physical Exam is the most documentation required.

IT REQUIRES NO "CODING KNOWLEDGE" OF THE USER
It’s the same systematic approach for any E&M encounter for every patient. You can be an expert coder, or coding ignorant. By following the simple steps, you end up with the expert code, regardless of coding knowledge, every time. Consistently.

IT'S TRANSFERABLE
Office staff can be trained to use this system to help save the physician more time. According to the rules, the physician must be personally involved with documentation of the History of Present Illness. But information gathering of all elements of the medical history can be conducted by anyone appointed by the physician…including an hourly employee or even the patient him/herself.

IT'S LINKABLE WITH HOSPITIAL DRG REIMBURSEMENT
Although physician E&M coding/documentation/reimbursement was Dr. Dunaway’s entrée to the “business of medicine world,” his work now involves connecting physicians and other elements of the “dots of healthcare” in meaningful, profitable ways. For hospitals, the byproduct of using Dr. Dunaway’s Documentation System is that documentation of multiple medical diagnoses is a consequence of physician documentation improvement. Documentation of multiple medical diagnoses feeds the diagnosis-driven DRG coding system reimbursing hospitals.

IT SIMPLIFIES AND ALLOWS PHYSICIANS TO REGAIN A MEASURE OF CONTROL
This system offers a streamlined approach to make coding and documentation improvement simple enough for any physician to use, and to regain a measure of control over a profession we have lost control of to the beancounters that run the “business of medicine.” As all of us in healthcare, individuals and institutions alike, are subjected to increased scrutiny over patient safety, evidence based medicine, and outcome analysis, documentation improvement through a rational, systematic approach maximizes caregiver future benefit.

Let’s look at the actual dollar amounts (not even RVU’s) of what Medicare is paying a client physician office of mine for a 99212, ($28.70); a 99213, ($39.46); and a 99214, ($61.99). So if you move a level 2 outpatient code up to a level 3, you just made your practice an additional $10.76 for doing NO MORE WORK other than using my system. Move a level 3 up to a level 4, you make and extra $22.53. (And this is just what Medicare is paying, not the co-pay…but since this is just an example, let’s call it the absolute profit increase.) And if you move the level 2 code up to a level 4 code (this will happen more than you’ll believe), you’ll increase profit $33.29. Fair enough?

If you’d rather use your own office’s Medicare payments, go ahead and plug in your Medicare reimbursements for the three codes. Calculate a conservative estimate of your increase in daily physician profit using this formula:

(x)(.2)($10.76) + (x)(.1)($33.29) + (y)(.2)($22.53) = $ Increase/Day

Where:

• x = (# of level 2 patients seen in one day)
• y = (# of level 3 patients seen in one day)

What we’ve set up is a hypothetical situation where ONLY 20% of your level 2 patients will increase to a level 3, ONLY 10% of your level 2 patients will increase to a level 4, and ONLY 20% of your level 3 patients will increase to a level 4. THIS IS VERY CONSERVATIVE. After you listen to the audio program, see the DVD, and actually understand how the documentation system is driven, you’ll see just how conservative this example is.

So Put In YOUR Numbers

How many level 2 patients do you see a day? 5? 10? 15? To be conservative, let’s say only 7. How many level 3 patients do you see a day? Again, conservatively let’s say 10. I know in reality you see more than this…but we’re being as conservative as possible. Again, this formula uses estimates of 10% and 20% (.1 and .2) factors of successful use of my system … again, very CONSERVATIVE. If I’ve been too audacious and too presumptuous with my example, plug in your own EVEN MORE CONSERVATIVE NUMBERS.

Using the example above, with the parameters specified by x and y, you’ll make $91.52 by my arithmetic.

That’s ONE doctor, using VERY CONSERVATIVE estimates. With that daily revenue increase, you’ve paid for the ENTIRE SYSTEM in less than 10 days.

Just imagine if you put in your real numbers, not conservative examples. How many days would this system take to pay for itself? Now take that tiny little $93.52 and multiply it by the number of days you work a FULL DAY ONLY. Don’t even think what it would do with higher paid codes in hospitals, or consultations, ONLY SIMPLE OFFICE VISITS!!!!! Just imagine.

Well, if you calculate you work only 40 weeks a year, four days a week, in a year’s time you’ll make (160)($93.52) = $14,963.20. Double check my math.

Could it be true? Could you really be leaving all this money on the table? In actuality, you’ll find it’s not true. You’re leaving even MORE money on the table…we just went as conservatively as possible to do these calculations.

What is your practice return on investment? Let’s see, for just you, one doctor, in a year, you’ve taken an investment of $895 and created a $14,963.20 return. By my calculations that’s a 1672% ROI.

YOU do the math!!!

"The coding principles I learned allowed me to increase my profitability by over $20,000.00 in one year."
Robert Trent, MD, California

"Very valuable resource. I have completely revamped my organization's coding and documentation process and have seen an increase in higher complexity codes, more consistent documentation among providers, and am utilizing the audit tool you provided for internal monitoring. Your information has been so beneficial I wish I had come across it sooner."
Karen, J. Cross, MD, FAAHPM, VP Medical Professional Services, Las Vegas, NV

"We revamped our progress note based on Dr. Tray's information and now my doc's circle and check instead of writing and writing. It has resulted in more information being captured with better coding skills and increased revenue."
Denise Lawry, Hartford Primary Care

"Within one day we have recouped through improved documentation your entire fee."
Greg Wise, Md, VP, Medical Affairs, Kettering Medical Center, Kettering, OH

"Your system is fantastic.I've been using it in my office and my revenues are up $4,000.00 to $5,000.00 per month."
J.D. (Primary Care), Washington State

"I first heard Dr. Dunaway two years ago and have used the risk-based approach to coding in educating physicians and when doing chart reviews. Great approach!"
Norma Herzog, Sumner, WA

"Dr. Dunaway's program was the most important thing to happen to me in my last four years of practice because he literally saved my practice. I implemented his coding system and discovered I could dramatically affect my bottom line. This made a world of difference in terms of reimbursement for all, but especially my Medicare patients. After using Dr. Dunaway's system, I had an independent review of my coding and billing. Not only was my bottom line dramatically improved, by my new codes, (averaging one level higher that before Dr. Dunaway), were appropriate. Thank you for saving my practice and teaching me how to code accurately."
Nancy Zega, DO, Ogden, UT

"I successfully educated our new neurologist in documentation of a complete chart note to allow appropriate billing of level 4 and 5 services. Previous documentation allowed a level 1 or 2."
Annette Dreifke, Franklin, TN

"Dr. Dunaway instills confidence that physicians can code what they do and get paid for it without fear of audits."
Gary Postlethwait, MD, Canton, OH

"Significantly decreased the number of charts that I have to amend or do over"
J. Michaelson, MD, Puyallup WA

"Tray has hit the bull's-eye on today's medical coding problems and where they came from as well as how to beat them at their own game."
Larry Andral, MD, Springfield, UT

"A a physician-taught /physician-perspective was used. Made a difference!"
Fiona Azybuiks, Fayetteville, NC

"For anyone in the healthcare profession that avoids understanding coding like the plague."
Diana Mousseau, CSW, Fayetteville, NC

"The 'Complete Idiot's Guide to Coding' without the yellow book! I didn't realize I could make the hospital money with my own charting!"
Michael Gerber, DPN, Troy, MI

"Dr. Tray has a true gift, the ability to take an overwhelming subject and compartmentalize it into simplicity."
Amy Partiseau, Milledgeville, GA

"Very well thought out, incredibly organized, and from a physician perspective. What more can you ask for? Well worth my time!"
Rob Ringler, MD, Chesapeake, VA

"It has helped tremendously. We're seeing an excellent return on the learning investment."
Valerie Kirby, Executive Director, Unicare, Inc.

"I thought Tray was going t make my life more complicated but he has done quite the opposite."
Walt Rooney, MD, Lovington, WA

"Hallelujah! A doctor who REALLY understands."
Cherrell Cole, RHIT, Prescott, AZ

"When I entered private practice, it was like I came out with a loaded gun, your system, for third party payers!"
Col. William Smith, MD

"Thank you for connecting the pieces of the puzzle in Coding."
Annette Carrow, DO, Royal Oaks, MI

"It is unbelievable that a general surgeon would take the time/effort to leave the OR to fight for others to take back the autonomy that we have lost to third party payers."
Pat Scanlon, MD, Jackson, MS

"Documentation for Dummies..Thank YOU! I liked the no-nonsense, 'numerical' approach as I will use this to structure my study and learning as I transition to private practice."
Harold Dillon, MD, Yorktown, VA

"Eureka! Finally a doctor that actually gets the game!"
Alice Fitts, RHIA, Hamburg, AR

"Fantastic - I'll never be a "loser" in the CPT game."
Carol Cunnelly, Durango, CO

"This helps eliminate the "gray" areas involved in picking the correct E&M code with straightforward steps to follow the rules."
Dottie Burkett, Farmington, NM

"This approach helps simplify a complex and foreign part of medical practice. I'm beginning to see the light - play by their rules, but play smart. I liked the commonsense approach."
Kirby Sweitzer, MD, Canton OH

"I fear for your safety. It seems that the insurance mafia might like to see you "out of business." I will pray for you. Simple to understand.and I don't have a headache afterwards..which is a first for something like this."
Mike Gooden, MD, Fayetteville, NC

"The real nuts and bolts of the process - Excellent."
Capt. Gary Ruesch, MD, Goldsboro, NC

"I'm a uro-gynecologist who is acting as my husband's practice administrator. I use Dr. Dunaway's approach with MDM and risk based coding to audit my husband's (interventional cardiologist) charts to assure compliance with AMA/HCFA guidelines. It has been an indispensable tool for me and is the only approach that makes sense to me and is clinically applicable. Dr. Dunaway is a great speaker on a dry subject that most lose interest in. His approach was first introduced to me at a Cardiology "Success" Meeting (Amer. Col. Cardiology) at the Atlantis Resort, (Bahamas, 2002). Before learning Dr. Dunaway's techniques, I never was able to figure out coding."
Lisa Beth Landly, MD, Tucson, AZ

Dr. Tray Dunaway holds a BS with distinction from Duke University where he graduated Phi Beta Kappa, Summa Cum Laude. He received his MD from the University of Pennsylvania and his post-graduate work in general surgery was completed at the University of Virginia and the University of South Alabama. He is a board certified surgeon and a Fellow of the American College of Surgery. He started a solo practice in Camden, South Carolina in 1986 and added two partners over the next six years. He later merged his practice to become a founding and principle partner in a multi-specialty practice.

Growing increasingly frustrated with physician loss of autonomy, diminished professional respect and reduced reimbursement in the 1990's, he attended a physician documentation/coding seminar in 1995. After suffering through two days of "coding education" Dr. Dunaway decided: (1) he had no interest in becoming a coder and (2) he needed a simple way to approach the complexities of E&M coding and documentation. He created a physician friendly, clinically oriented methodology that would become known as Risk Based Coding. Best of all, it required no “coding knowledge” for physicians who also wanted to improve documentation and coding accuracy but didn't want to become coders either.

In 1997, Dr. Dunaway published his Risk Based Coding methodology in Pocket Guide to Clinical Coding. Asked to speak on "coding" by the South Carolina Surgical Society, this led to a series of engagements and he started speaking professionally. His animated contrarian physician perspective coupled with irreverent humor backed up with a healthcare insider’s knowledge soon made him an in-demand speaker and he immediately attained professional membership status in the National Speakers Association. Dr. Dunaway is currently the only physician to hold the highest earned award of the National Speakers Association, the CSP (Certified Speaking Professional) designation, and the first ever surgeon to hold this distinction. Other coding aids and books using the Risk Based Coding methodology were created and eventually evolved to become Dr. Dunaway’s Risk Based Coding™ System.