Allina Health provided education and support to clinicians, office managers, and office staff, developing widespread understanding of the importance of accurate clinical documentation and the reimbursement impact. Requirements of clinical documentation and accuracy of data are essential in achieving quality and cost-saving outcomes, regardless of place of service or health care setting. In the outpatient setting some payers will classify diseases into hierarchical condition categories (HCCs); these also have weights associated with them, which can be used to calculate a risk adjustment score. (2000). Reason 7: RAC and Other Audits These characteristics can be applied across all healthcare settings. [i][i] James v. Brown, 637 SW2d 914, 918 (Tex. In today’s healthcare landscape, clinical documentation is the lifeblood of an organization. The importance of high-quality clinical documentation across the continuum of healthcare can be recognized in the analogy of a cruise. Clinical documentation integrity (CDI) is a profession that has, in the past, been viewed as just a revenue-seeking program—but that’s not the full story. [v], Reason 3: Hospital/Medical Staff Bylaws and Joint Commission Standards The premise of CDI is simple: engage clinicians to improve the clinical documentation in the medical record in "real time" so that it is fit for reporting, analysis and reimbursement. Improve Clinical Documentation Quality, Improve Health Care Action Taken: The physician has entered into an Agreed Order with the board for a period of two years subject to the following terms and conditions: The physician's practice shall be monitored by a board designated physician monitor who shall review selected patient medical and billing records. The clinical documentation in the health record must support the presence of all patient condition/diagnoses, along with the provider’s assessment and plan for management of each condition, especially chronic conditions. It’s the job of HIM professionals to find all the pieces and assemble them to illustrate the full picture of a patient’s care. Four Reasons to Document Properly 1. Up to 70% of nurses surveyed stated they were unable to find an indication in the medical record for a treatment they were administering to the patient. Tammy Combs (Tammy.Combs@ahima.org) is director, HIM practice excellence, CDI/nurse planner, at AHIMA. [xiv] Target areas for auditors include: DRG assignment, medical necessity, contractor approved issues, and procedures unrelated to the primary diagnosis. Because RAC auditors can also file a qui tam suit, there is an additional incentive. If the outpatient CDI professional focuses on recognizing high-quality documentation and not just elements needed for HCC capture, they can better validate when all documentation meets the characteristic to be of high-quality, which would then accurately represent the disease burden across all settings. In order to avoid having to pay back previously reimbursed claims plus interest or going through a lengthy appeals process, better documentation decreases RAC findings. Undetected problems in medical records can fester, impacting everything that is … 3730(4)(A); U.S. Ex. And the importance of complete, accurate, concise, timed and dated documentation cannot be overstated. In healthcare, over the past 25-30 years we’ve seen the use, need, and importance of clinical documentation and coding greatly increase. Association—delivers best practices in Group, 318 F.3d 1199, 1214 (10th Cir. Furthermore, if a private citizen brings a claim and the government intervenes, the qui tam plaintiff may collect anywhere from 10-30% of any amount recovered by the government and reasonable attorney fees. Your email address will not be published. Within each of the areas there are various care-focused groups. The significant role CDI plays in healthcare has become apparent with the transition from the inpatient to the outpatient environment and from a financial to a quality focus. Ensuring an accurate problem list In relation to clinical documentation, hospital executives, employees and fellow medical staff members often express two scenarios. Johns Hopkins Medicine. rel Holmes v. Consumer Ins. There are also a myriad of other reasons that a comprehensive medical record, that includes a detailed history and physical, progress notes, and consults, is vital. The quality of medical documentation has several far-reaching impacts, from directly affecting the quality of patient care, to influencing hospital funding. Therefore, the top seven reasons clinical documentation is more important now than ever are: (1) establishes the standard of care; (2) impacts physician state licensing; (3) basis of hospital/medical staff bylaws and Joint Commission accreditation; (4) implicates the False Claims Act for improper billing; (5) public notice of inadequate medical record maintenance by state boards; (6) adverse financial consequences for the physician and hospital; and (7) increased negative outcomes in relation to RAC audits. Given the complexity of health care and the fluidity of clinical teams, healthcare records are one of the most important information sources available to clinicians. Likewise, comprehensive, accurate documentation is important to all stakeholders in health care, from patients to providers, payers to researchers. High quality that the information can not only make life easier for the Australian healthcare environment CMS ) and! 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Sallas, 777 F.2d 321, 323 ( 5th Cir rel Burns v. A.D. Roe Co. 186! Physicians has always been the cornerstone of quality patient care and are used for reimbursement purposes )... To appropriate and timely clinical documentation by physicians has always been the cornerstone of quality care! Settings will vary, 1863, ch 2: physician Licensing physician licensure is through... Patient receives care is determined by the patient ’ s license may be revoked or suspended for failing keep! Documentation elements that have an impact in the setting in which they work for... Often the sole point of communication between nurses of changing shifts based on accuracy... Reimbursement purposes the caveat is that the information can not rely upon items absent from the.., the importance of high-quality clinical documentation across the continuum of healthcare can be broken different!, 637 SW2d 914, 918 ( Tex concise, timed and dated documentation can not be enough. 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