At the core of every patient encounter and vital to the success of modern practices and hospitals is a good Clinical Documentation Improvement (CDI) program. By providing information to members of the care team as well downstream entities that may provide care at a later date, CDI has a direct effect on long-term patient health and leads to increased revenue.
Clinical Documentation Improvement Means Better Patient Care in 2018
Your entire staff, processes, and technology must work together for your CDI program to be a success. Leading your program you need a well-rounded individual or team who can effectively articulate all the pieces: documentation requirements, coding assignments, coding guidelines, and quality reporting.
Your CDI program must be accurate, timely, and provide the accurate representation of a patient’s clinical status that translates into coded data. These coded data are then translated into quality reporting, physician report cards, reimbursement, public health data, and disease tracking, and trending. Needless to say, ensuring that your coding team is well-trained and updated on coding changes is essential to your success.
2 Main Reasons Documentation is Important in Healthcare
A successful CDI program will offer many benefits and the two most compelling ones are as follows:
- It allows physicians to share essential patient care data with other caregivers and interdisciplinary teams, thereby improving quality.
- It improves and optimizes claims processing, improving systems and increasing reimbursement.
These key benefits are highly desirable for any practice or hospital and yet they can be difficult to achieve. Physicians are not trained in clinical documentation improvement and once they are fully ensconced in the riptide of daily practice, few have time to learn. Along with alphanumeric codes, ICD-10 increased exponentially the need for clinical documentation. If the dots aren’t connected then neither is the revenue. Documentation must:
- Be specific and granular
- Meet all regulatory requirements
- Meet all reporting requirements
- Reflect accurately all of the care provided
Accurate reimbursement for patient care, especially for those with chronic disease or multiple diagnoses, is directly related to the detail and accuracy of the clinical documentation. That is why implementing a CDI program that can identify documentation gaps, produce the the correct ICD-10 code, and notify staff is not only essential, it’s imperative.
Clinical Documentation Guidelines For A Successful CDI program
CDI programs aren’t a new concept. A quick internet search will find many specialists who can help you design and build a successful one. Some factors to consider if you are designing a program from scratch:
- Your budget and necessary resources (e.g., software, staff, service and support)
- Your needs assessment (e.g., gap analysis, types of review offered [before discharge or after discharge])
- Your program leadership and management
- Your program training, maintenance, evaluation, and upgrades
The foundation of any program is, of course, your coding team. You must ensure that your team is well-trained in both ICD-10 and CPT codes, updated on any and all changes, and able to handle the challenges of your new system. Without the right coding solution in place, your CDI system will not be successful.
Documentation is Complex
A quick review of the ICD-10 requirements for just one of the common conditions seen in primary care illustrates the documentation challenge. For treatment of hypertension physicians are required to document its type, associated complications, severity, symptoms with findings, and temporal factors. It can require documentation of 16 or more data points. Dermatitis requires a review of 29 data points. If that’s just one condition for one patient, multiply that by multiple conditions in multiple patients and you quickly see how documentation challenges grow. Although learning how to connect the dots with multiple diagnosis patients may not be on the top of a physician’s list, it can cost valuable revenue dollars. A lack of CDI may lead to one code, when in fact another more-comprehensive and higher-reimbursable code is in order.
The point is this, if doctors know how to correctly capture and document the full extent of care provided to each patient, this delivers to the coders a comprehensive picture of the care delivered. That in turn becomes a clear, comprehensively coded claim that has the best chance for full and proper reimbursement. Anything less leaves money on the table.
Effective CDI can increase reimbursement
Addressing CDI complexities requires a robust support system with advanced technology. It should streamline the process and become an integral part of workflow. It should accurately direct doctors to queries and pick-lists that lead to the selection of diagnoses that give coders maximum, clear information. To be effective the CDI program must:
- Capture documentation and use it to produce codes for maximum reimbursement
- Produce reports that can be used to accurately portray quality of care
- Document physician care to improve communication among care teams and improve patient safety
- Document specific diagnoses and avoid documenting symptoms (as physicians often do) that can’t be coded
Although CDI may be seen by physicians as one more administrative headache keeping them from patient care, it is the best tool to increase reimbursement. After all, you and your physicians did not go to medical school to simply become documentation experts. But documentation will lead to better care for each patient, something that all physicians can get on board with.
Involve Physicians Facilitates Buy-In
A clear program design and effective training can help your physicians understand how poor documentation can lead to lost revenue. For example, if your facility has an acute care patient with pneumonia, and she is going through different levels of care and different stages, you need to have exact documentation. If something has not been documented appropriately, your organization is at risk of not following through with the next level of care.
Proper documentation shows that your team has provided quality care, and passes valuable information to any other physicians, nurses, physical therapists, respiratory therapists, or specialists your patient may see. The right documentation also ensures that your organization gets all the reimbursement dollars that you are rightfully owed for the care your team provided.
Once the CDI learning curve is mastered, denials may be substantially reduced, successful claims increased and revenue enhanced. It’s the very definition of short-term pain for long-term gain.