Those of us who work in Health Information Management understand the value of good documentation — and we have especially keen senses when it comes to recognizing excellent documentation when we see it. That being said, we also know when we’re seeing documentation that isn’t so great. And together with medical billers and coders, we’re always looking for ways to improve it.
Revenue Cycle Improvement – Clinical Documentation Improvement
Clinical Documentation Improvement programs (CDI) have been cropping up in hospitals nationwide as hospital systems are feeling the heat to reduce their denials. By implementing CDI programs, healthcare systems provide health professionals with more guidance regarding their documentation. In a world where the EMR has an increasing, and often frustrating, clinical presence– doctors need to enter a symbiotic relationship with the technology in order to produce the kind of documentation that will not only support their clinical decision making, but that will be clearly coded and billed to the insurance companies, assuring the maximum reimbursement, and revenue cycle improvement is attained.
For already overworked physicians, this seems to be an insurmountable challenge. Man may feel that having CDI programs “looking over their shoulders” takes away from their hard earned autonomy. But CDI programs are here to help, not hinder, a physician’s clinical documentation.
Revenue Cycle Improvement – Recovery Audit Contractors
One of the major auditing bodies, the CMS Recovery Audit Contractors (RAC) are largely focused on medical necessity. Since the RAC requests patient records for their auditing purposes, the documentation needs to be able to stand up on its own against their scrutiny. If not, then hospitals are looking to lose a significant amount of money in “take backs” of payments. The only way to combat these “take backs” is through a process of appeals, which is a costly endeavor in and of itself. While CDI programs are not solely concerned with assessing documentation for medical necessity, since CDI nurses spent so much time viewing the records, they are often the first to bring a unsupportive diagnosis to a case manager.
For example, if a CDI nurse is reviewing a chart and sees that the principal diagnosis of syncope is not likely to support the inpatient stay, it would behoove them to bring that chart to the attention of case management for further review before it lands in the RAC’s hands. CDI programs can serve as the first line of defense against failed medical necessity edits.
It is possible for there to be a clear differentiation between CDI and case management programs, but increasing interoperability between them will only stand to improve documentation, and in turn, reduce costs and fees.
Revenue Cycle Improvement – What Constitutes Good Documentation?
1. The documentation is clear and supportive.
Although there have been ongoing jokes about not being able to read a doctor’s chicken scratch handwriting, in the days of the largely electronic record, the issues with clarity come less from the words and more from the structure. It’s imperative that the documentation not only support the diagnosis, but show a unencumbered, linear progression in the decision making process.
2. The documentation has no errors.
Sometimes, errors in transcription (particularly when using voice recognition software) are not the fault of the physician. Usually, though, they are caught by the HIM professionals processing a patient’s record. While they can’t alter the documents, they can refer them back to the physician’s office for correction. While it may seem like unimportant clerical work, sometimes, these errors are not simply a missing comma or a misheard word — an extra zero on a medication dose could be fatal at worst, but mostly just an embarrassing oversight.
3. The documentation is correctly formatted and provides clear directions on where it needs to go once it’s complete.
Many EMR’s come with templates that physician’s can use for their dictation, so the formatting is less up to them and more up to the HIM professionals who set them up. That being said, consideration and collaboration should occur in the creation of any new work types or templates for dictated notes. Furthermore, if the note needs to go to a physician, nurse practitioner, or other healthcare professional, the more information that can be provided about the recipient, the more likely it is to arrive in a timely manner. In some hospitals, this is all automated through a faxing application. But sometimes, a human being actually needs to send the fax – and having a correctly spelled name, correct credentials and even an affiliated hospital or telephone number saves time and ensures that the intended recipient gets the note.
So what are the ramifications of poor documentation?
● Greater administrative burden — for HIM staff, medical billers and coders, case management and the physicians themselves. The more time spent in the patient’s chart, trying to fix problem areas, takes time away from coding records. The less records that get coded, the greater the lost revenue for the hospital.
● Medical coders, while versed in medical terminology, are still technically non-clinical members of a healthcare organization. That being said, if documentation is not clear, or is contradictory, it’s more likely to be coded incorrectly if the coder reviewing the chart doesn’t get a clear picture.
● There are ramifications for the patient and their continued care if the justification for tests or imaging is not clear within the physician’s documentation of the visit. Not only can this influence further treatment by other doctors, but can be a prime target for insurers to reject the claim if they feel the treatment wasn’t medically necessary. This is why it’s generally not a good idea for the documenting physician to expect another doctor, later on down the line, to make inferences about what is in the note.
CDI programs do a lot more than the few things mentioned above, and because these programs are still being piloted, input from healthcare professionals is essential to their evolution. The potential of CDI programs is great; but HIM professionals and clinical staff need to work together to reap the benefits.
If you need assistance with revenue cycle improvement and getting your clinical documentation under control, contact us:
BHM Healthcare Solutions
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