What is it?

3 words: Coding Cliff Notes.

Forced by his office manager to attend a “coding seminar” in 1995, (doesn’t that make you want to yawn?), Dr. Dunaway realized two things: 1. There was a lot of “coding and documentation” information he needed to understand, let alone, apply to actual daily patient encounters and B. He didn’t really want to become a coder. For a guy who can’t keep his 1’s and 2’s distinct from his A’s and B’s, he realized he didn’t want to have to learn all the rules to understand all the rules, only how to use the rules. We’re doctors, not coders! To open a lock, you don’t have to understand how the lock works; you simply must have a key that opens the lock.

The key that solved Dr. Dunaway’s E&M (Evaluation and Management) coding conundrum was to adopt a clinically friendly approach to ensure correct coding based on simple directions, not complex rules. Dr. Dunaway created a systematic approach, (simple enough for even a general surgeon to understand), for any E&M encounter. All physicians who do E&M documentation for inpatients, outpatients, consults, home or nursing home visits could now use third party payer rules, our way. Without having to become a coder! And because the approach is based on a compliance correct methodology, it will render physicians bulletproof from auditors while allowing the physician to receive full measure of the A. Credit and Recognition and 2. Reimbursement that correct coding and documentation yields.

Starting out as a little pocket notebook Dr. Dunaway used personally for two years, the approach was initially published as Pocket Guide to Clinical Coding. To make inpatient follow up visits easier to code, document and record, the Coding Checkbook was created. Flexform was developed as a single page template for physicians who write their encounters for any level inpatient, outpatient, or even consult E&M documentation. The Rapid Inpatient Guide was initially created for a national hospitalist group, but was adapted to serve inpatient and outpatient physicians as well as physician assistants, nurse practitioners, or even other office personnel. The Risk Based Coding approach is used throughout the documentation system.

Audio and DVD programs were created to benefit physicians who had never seen a physician education program given by Dr. Dunaway as well as providing education for physician employees as well as a manual to bring the reader step by step through optimal use of the Pocket Guide and other documentation tools. Dr. Dunaway’s pocket notebook evolved into a documentation system that has worked for thousands of physicians to not only improve accuracy of E&M documentation, but to save physicians time, get full measure of reimbursement and never to fear an auditor again. And, best of all, physicians don’t have to become coders and it's FAST!


How it works
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5 words: Uses their rules, our way.

Auditors start with a billed E&M code. This code must be supported by documentation. Depending on the code, various elements of documentation must be present. If they are absent, the code is unsupported and requests for refunds can be made in post-payment audits, payment can be denied in pre-payment audits, and after the passage of the Kennedy-Kassebaum Bill, all third party payers, (state, federal, or private), can prosecute for “fraud and abuse” based on E&M coding/documentation variances. As physicians we typically think of “documentation” as a brief note to remind us where we left off. Third party payers think of “documentation” as the sole reason to fulfill a contractual obligation with an insurance beneficiary. There is a fundamental cultural difference on how documentation is viewed between caregivers and caregiver payers.

By aligning third party payer rules of reimbursement, and therefore auditor rules, with how a code is selected and supported with documentation by physicians, satisfactory results are achieved by both cultures. But the problem physicians have with this is that heretofore it was necessary to attend “coding seminars” to gather information, convert that information into knowledge, and then, (the hardest part), to use this knowledge to implement change in how we conduct coding/documentation.

How many H&P’s has an auditor done? Not audited, but actually done? How many E&M audits has a physician done? Typically, the same number. Zero. When you go to a “coding seminar,” who teaches the coding? A physician or a coder? Isn’t it interesting that the auditors and coders who review physician documentation have never actually done a H&P and that most physicians don’t have the foggiest idea of how to do an E&M audit on their own documentation? Because physicians and coders/auditors approach a H&P from different perspectives, they see the same thing differently. When a coder/auditor approaches E&M documentation, they see words on paper. When a physician approaches a documentation encounter, the paper is blank. Coders code by what’s been written down. Physicians write down what’s important to physicians, not coders/auditors.

By breaking down the key components of an audit and rearranging these elements in a clinically usable format, physicians can effectively use “their rules, our way.”

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 Documentation 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).

Risk Based Coding Documentation 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).

Ever wonder why we had to learn all that chemistry in college? This is chemistry! You can drive the equation either direction, (H&P --> CPT) or (CPT --> H&P). It’s not correct either way, it’s correct both ways. 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
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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&P’s, but Medical Decision Making (MDM) is more mysterious. That’s where the understanding pays off.


Medical Decision Making (MDM)
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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. Say, here's a thought: 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 thousands of other physicians who now use it daily.

1. Risk is formally assessed for a patient encounter using AMA/HCFA 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™ 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.

Risk	Data	Diagnosis	MDM
Minimal	1 Minimal	1 Minimal	Straightforward
Low	2 Limited	2 Low	Low
Moderate	3 Moderate	3 Multiple	Moderate
High	4 Extensive	3 Extensive	High

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.” (Naturally, this is my favorite part of the whole deal….me a coding dummy, getting the expert code and not having to actually understand a blessed thing about coding, only the ability to follow simple instructions.)

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.


Example of Risk Based Coding™ Application
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How about a real application of how the Risk Based Coding Documentation System functionally operates? Without using the system, I previously would have jotted a short note on a consultant form, provided by the hospital. I’d have everything I or any other physician would need to justify clinical decisions, but that’s not the point. I rail why can’t we just document clinical information on 3x5 cards? The answer is we can. We just don’t get paid for this style of documentation!! If a physician decides to practice medicine as a hobby, and not as a way to earn a living, get 3x5 cards. But if you need to earn a living in medicine, read on.

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, just before my first publication of Pocket Guide to Clinical Coding. All identification information has been deleted to maintain privacy. (Like we needed HIPAA to tell us this!)
In brief, there are seven steps to employ Risk Based Coding Documentation.

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.

Example:
Here it is, as reproduced for this webpage from the actual hospital transcript. All italicized text is added as commentary.

KERSHAW COUNTY MEDICAL CENTER
CAMDEN, S.C. 29020
PATIENT: XXXXXX RM #: XXXX MR#: XXXXX
REPORT: CONSULTATION REPORT PT# XXXXXXX
CON DOCTOR: M. Tray Dunaway, MD, FACS ADM DATE: 09/XX/97
ADM DOCTOR: XXXX DICTATED: 09/XX/97
TRANSCRIBED: 09/XX/97

CONSULTANT: M. Tray Dunaway, MD, FACS DATE OF CONSULT: 09/XX/97
99245-57

The first documentation is the appropriate E&M CPT code, with modifier to get full credit for the E&M service, in addition to the forthcoming surgical service. The accurate CPT code is ready for my office coder.

REASON FOR CONSULTATION:
I was asked to evaluation this patient for possible appendicitis by Dr. XXXX

CHIEF COMPLAINT: using the key elements of the H&P auditors look for, in the patient’s own words.
“My belly hurts when I move around.”

EXTENDED HISTORY OF PRESENT ILLNESS: using “extended” telegraphs to auditor that the physician understands precisely the rules and how to use them.
This is a very healthy 17-year-old who noticed the gradual onset of a generalized abdominal discomfort yesterday associated with some nausea. No vomiting. No diarrhea. No change in bowel habits. This morning, by 0900, it had localized to a very tender right lower quadrant exacerbated by movement, relieved by rest. (At least four of the “location, duration, quality… qualifiers are documented to meet the requisite components of the “extended HPI”)

PAST/SOCIAL/FAMILY HISTORY

Past: No meds, NKA, previous illnesses, Past surgery wisdom teeth extraction 1996 Technically, could list only one entry...but musn't lose sight of the fact that a good medical history is done primarily for patient benefit, not for reimbursement!

Social: High School Senior, - tobacco/etoh (again, technically, could list only one element...like "doesn't smoke unless on fire!"

Family: Parents A/W in mid 40's

COMPLETE REVIEW OF SYSTEMS:
Gastrointestinal: Otherwise unremarkable. The remaining 13 AMA/HCFA guidelines recognized review of systems are negative. (Again, using acceptable “rules” signals an auditor, that the doctor knows exactly what is going on with regard to necessary documentation. And, as this example illustrates, knowledge of what is acceptable documentation, makes this ROS a snap!)

COMPLETE PHYSICAL EXAMINATION:
CONSTITUTIONAL: Temperature 96.8Œ, Pulse 76, Respirations 20 Blood Pressure 138/70.
GENERAL: Well-developed, well-nourished, with good grooming.
HEAD, EYES, EARS, NOSE, AND THROAT: Eyes: Normal conjunctiva and lids. Pupils and irises; Pupils are equal, round, and reactive to light and accommodation. Ear, nose, mouth and throat unremarkable, Lips, teeth, and gums are good. External ears and nose are unremarkable.
NECK: Supple without thyroidmegaly, enlargement, tenderness, and masses. There is symmetry in the neck.
LUNGS: Respiratory effort easy. Percussion normal. Auscultation of lung sounds are normal. He has no costovertebral angle tenderness.
CARDIOVASCULAR EXAM: he has an S1 and S2. There is no S3, 4, or murmur. Distal pulses intact. Carotid arteries reveal normal pulse amplitude. No bruits.
CHEST: Normal breasts. No masses, lumps, or tenderness.
ABDOMEN: Muscular. Normal contour. There are no scars. No engorged veins. No umbilical nodularity or hernia. On auscultation he has normal bowel sounds which are slightly diminished. There are no rushes, bruits, or friction rubs. On light percussion and palpation, he has some direct tenderness over the right lower quadrant. On percussion, he has distinct percussed tenderness on the right lower quadrant. I did not need to do rebound tenderness. On deep palpation, he has no hepatosplenomegaly. There is a distinct right lower quadrant tenderness over McBurney’s point.
RECTAL EXAM: Anal examination revealed normal external examination. No masses found with the digit and it reproduced pain in the right lower quadrant on palpation.
LYMPHATIC EXAM: There are no neck, axillary, or groin lymphadenopathy.
SKIN: No subcutaneous nodules. No rashes, lesions, ulcers.
NEUROLOGICAL EXAM: He is grossly normal to motor and sensory exam.
PSYCHIATRIC EXAM: His judgment and insight are good. He is orientated to time, place and person. His memory is good. There are many elements I would not normally report in this type of history for simple clinical charting, but using the dictatable format the Risk Based Coding Documentation System provides, the necessary details as required by AMA/HCFA(CMS) guidelines to support the code are easily covered.

RISK LEVEL: This patient has a high level of risk as determined by AMA/HCFA guidelines because he would need emergency major surgery, specifically an appendectomy.
AMOUNT AND COMPLEXITY OF DATA REVIEWED OR ORDERED: Evaluation of the urinalysis which was negative and a WEB of 13.8 with a shift to the right is noted. This is a limited amount of data.

NUMBER OF DIAGNOSES MGMT. OPTIONS: However, this does represent a new problem and an additional work-up is indeed planned which specifically is a laproscopic approach to rule out appendicitis. Therefore, overall, he has a high complexity of medical decision making. This documentation would be very unusual for the vast majority of my previous H&P’s, but it underscores all the details to verify the correct level of medical decision making. Risk, Data, and Diagnoses are all specified, which leads to the correct MDM. And let me tell you, when an auditor reads this paragraph, it simply blows ‘em away. There is absolutely no doubt that the physician understands and knows how to use the rules.

IMPRESSION:
Probable appendicitis. He has all the signs and symptoms I look for. The fact that he is not febrile does not dissuade me too much. He has not taken aspirin or antipyretic agents but looks to fit the problem. His family understands that there is a possibility that it is not appendicitis and that the only real way to treat this is to proceed with appendectomy.

PLAN:
I plan to do a laproscopic approach. There understand that this may be abandoned for an open procedure. Parents have given written consent for surgery.

M. Tray Dunaway, MD, FACS

MTD///ph
Cc: xxxxxxxxx, MD

It’s not that my before Risk Based Coding Documentation System records I did were worthless, they did serve to “complete” medical record requirements and get my patients with appendicitis to the OR, it’s just that the after using my system records are worth lots more! By the way, this kid did have appendicitis and went home just 8 hours after his laproscopic appendectomy. Using my Pocket Guide to Clinical Coding, this dictation followed the outlined steps in short order on the hospital’s dictation system. Compliance correct documentation resulted in the correctly E&M coded encounter, which ultimately resulted in correct and full reimbursement for this patient evaluation.


Why it works
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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 is very fast in it’s application. 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 hospital 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.
A streamlined approach to make coding and documentation improvement simple enough for any physician to use 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 is in healthcare, individuals and institutions alike, are subjected to increased scrutiny in regard to patient safety, evidence based medicine, and outcome analysis, documentation improvement through a rational, systematic approach maximizes caregiver future benefit.


About Rebel Records
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Rebel Records, Inc. was created to serve as a publishing company for Dr. Dunaway’s first publication and has subsequently produced the majority of his publications. It describes a rebellion from traditional physician medical record documentation that is designed to make physicians and hospitals money, save physician time, never fear an audit again, and to build a better connection between not only physician and hospital dots of healthcare, but between payers and patients as well.


Impact and financial findings
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1 word: Substantive

For physicians and hospitals Dr. Dunaway’s system has resulted in increased immediate and long term financial and relational capital building results.

- Financial Impact--Through the use of Dr. Dunaway’s Risk Based Coding Documentation System, physicians and hospitals alike have improved reimbursement by millions of dollars.

Physicians learn to correctly code and document results in substantive financial rewards.

“Your system is fantastic. I’ve been using it in my office and my revenues are up four to five thousand dollars a month.” J. Duris, MD, Puyallup, WA

“The coding principles I learned allowed me to increase my profitability by over $20,000.00 in one year.” R. Trent, MD, Redding, CA

“[Dr. Dunaway] literally saved my practice. In only one day, I implemented his coding system and discovered I could dramatically affect my bottom line.” N. Zega, DO, Ogden, UT

Hospitals report significant financial results:

“…within on day we have recouped through improved documentation your entire fee.” Gregory R. Wise, MD, FACP, CPE, VP. Medical Affairs, Kettering Medical Center, Kettering, OH.

“The improvement in physician charting has been rapid and dramatic” Marcia G. Stickler, JD, Compliance officer Mental Health Division State of Washington Hospitals

“In just 5 cases, were were able to discuss with the attending physicians what documentation was necessary which amounted to an increased reimbursement of $12,328. Simple pneumonia was our top DRG and in one month, it dropped to third.” David Glrmsen, DO, CMO Mercy Medical Center, Canton, OH.

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

“I guess the greatest example of successful outcome is the memory by physician, over one year later, of the impact on their work on the floor. Your success at motivating physicians has helped lead to a dramatic improvement on appropriate inpatient documentation.” Debra K. Kellerman, Director, UR/Case Mgmt., Holy Family Hospital, Spokane, WA

- Relational Capital --The ability to connect physicians and hospitals through application of Dr. Dunaway’s Documentation System will impact physician/hospital relationships beyond “coding and documentation” and serve as a springboard for improved understanding and symbiosis.

“Thank you for the immediate and lasting impact your presentation in September 2003 had on our organization. Positive results have been observed in terms of improved communication between physicians and Health Information Management staff, particularly medical coders. Further improved response rates to physician queries and improved documentation have been seen, especially in regards to acute blood loss anemia.” Steve Bateman, CEO, MountainStar Healthcare

“The active role you have taken in bridging the gap between physicians and hospitals have given trustees and CEO’s a better understanding of how to establish common ground with the medical staff.” Tambra Medley, Director of Association Services, SC Hospital Association.

“A refreshing new approach to one of the oldest problems in healthcare – physician relationships.” Kathy Morrissey, Redding, CA

“Hats off to you! You are a doctor’s doctor, a coder’s ally and an administrator’s hero. Thanks for your unique ability to help all of us understand how much we depend on each other in order to survive in today’s complex healthcare arena.” Lyn Willett, RHIT, Director, HIM, Deaconess Medical Center, Spokane, WA

>> What is it?

>> How it works

>> A Word of Caution

>> Key E&M Components

>> Medical Decision Making

>> Risk Data Diagnosis

>> Example of Risk Based Coding

>> Why it works

>> About Rebel Records

>> Impact and Financial Findings

What they are saying:

“Your program has helped our broup to confidently increase our billing. I have used your books to effectively streamline the documentation in our physician based forms. We are now compliant, successful, and enjoying more, what we got into this business for, the practice of medicine. it’s good to beat the insurance companies at their own game... thanks for the guidance!”

Paul Krause, MD, Truckee, CA

"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

”I’m already doing the documentation….now I know how to do the correct coding!!!! This will dramatically increase my bottom line!!!”

Nancy Zega, DO, Ogden, UT.

“Hallelujah! A doctor who REALLY understands.”

Cherrell Cole, RHIT, Prescott, AZ

"I've used your approach for several years now. Works great. I code what I do, do what I code, and document everything to the level required. I have not yet failed an audit. Best yet, no more anxiety or frustration. Thank you, Tray"

Mark Hirschkorn, MD

“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. I loved his attitude, excitement, content and props!”

Pat Scanlon, MD, Jackson, MS

“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

"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

“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

“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

“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