Clinical documentation improvement (CDI) is not taught in medical school, and persuading physicians to document thoroughly and effectively is a lesson in futility, as they usually believe it’s not important. However, this viewpoint can significantly impact their finances as physicians are increasingly being subjected to pre- and post-payment audits. Due to changes in reimbursement and increased scrutiny by third-party payers, clinical documentation improvement has become even more of a strategic imperative than ever before.
Clinical documentation is at the core of every patient care because it not only validates the care that was provided, but also because it shares data with the subsequent caregivers and optimizes claims processing. In order to be meaningful, it must be accurate, timely, and reflect the scope of services provided. A good CDI program enables the accurate representation of a patient’s clinical status that translates into coded data, which is then translated into quality report cards, physician report cards, reimbursement, and public health data.
Why clinical documentation improvement is so important to hospitals
Physicians might not be quite in tune as to the impact poor documentation can have on the bottom line, however, there are three real reasons how this can negatively affect an organization.
- If it is hasn’t been documented it hasn’t been done
Documentation supports coding which is the basis of correct revenue and reimbursement. Otherwise, a hospital is at the risk of losing revenue. For example, if a hospital has an acute care patient who has pneumonia, and that patient is going through different levels of treatment and different stages, there needs to be exact documentation.
- Documentation is necessary for complying with quality measures
It shows that good quality care has been provided to the patient. Plus, it also provides valuable information among an interdisciplinary team of physician, respiratory therapist, nurses, physical therapist, etc.
- Quality information supports care management and makes sure protocols are followed
Clinical documentation improvement provides quality information, which in turn supports care management and ensure that protocols are being followed.
The Comprehensive Error Rate Testing (CERT) Program
Medicare has designed CERT program to help providers understand how to provide accurate and supportive medical record documentation. Under this program, CMS selects a random sample of claims from each Medicare contractor and requests medical records from the providers who submitted those claims. These records are then reviewed to determine if the claim was submitted and paid properly under Medicare coverage, coding, and billing rules.
The CERT Program releases two figures every 6-month that are calculated on the basis of a review of more than 100,000 Medicare patient encounters. Although the types of errors vary, the below mentioned errors are consistently topping the error categories as part of the physician medical record sample.
- Documentation in the medical record for the patient encounter does not support the level of physician E/M code billed.
- Patient complaints are not visible in medical records
- The medical necessity for the care provided was not apparent through review of physician documentation
- The medical record documentation does not validate that the physician actually evaluated the patient.
- Physician not signing and dating the progress note
The errors identified above by the CERT program could have been avoided by simply requiring physicians to ensure each medical record answers the 5 basic questions — who, what, where, when, and why.
In an upcoming session on CMS guidelines for physician documentation, expert speaker Melody Irvine will look at some actual documentation errors that are found in the medical record. You can attend this session to know about things to watch out in your physician documentation and how it affects the physician’s reimbursement.
