Research reveals that a lack of adequate clinical documentation is a problem throughout the healthcare industry. While high-quality documentation is always sought, it remains uncommon within most healthcare settings.
Provider documentation is the sole data source for coding professionals, reimbursement and public reporting. Coding professionals use documentation in the patient record and translate it into ICD-10 codes using very specific Centers for Medicare and Medicaid Services (CMS) and National Center for Health Statistics (NCHS) within the US Federal Government’s Department of Health and Human Services (DHHS) guidelines. Once these codes are submitted via claims, the data is used to develop perceptions of performance in quality of care, mortality/severity of illness scoring, length of stay and readmission rates.
Consumers are more aware of, and are choosing facilities/providers based upon scores provided by governmental agencies, accrediting organizations, or non-profit organizations such as health grades and US News and World Report. Some of the challenges with these scoring systems are the potential inaccuracy of data and the possibility that it may be incomplete or old. Scoring systems are proprietary. One organization’s rating attribute(s) may be different from another organization’s depending on the focus of the score/rating. It is up to the patient to interpret these scores and determine where to seek care.
Payers are also moving from fee-for-service to fee-for-value reimbursement models in an effort to strategically manage costs while also requiring improvements in care quality. Providers and payers alike struggle with incomplete or inaccurate claims based upon incomplete documentation. Per Becker’s CFO Report, June 26, 2017, a study by Change Healthcare Healthy Hospital Revenue Cycle Index found there are many reasons for denials, and the second leading cause is missing/invalid claim data (14.6%).
An effective CDI program can help solve this problem. CDI programs are considered a bridge between a host of professionals, including physicians, mid-level providers, case management, coding, quality management and financial services.
The goal of an effective CDI program is to support medical staff efforts to most accurately depict:
- The patient’s comorbidities on presentation
- What caused the patient to seek treatment
- What happened during treatment
- Reasons for resource utilization
- Reflection of personalized, quality medical care
- Continuum of care on discharge
Clinical documentation education is often not provided during medical training. CDI programs help providers understand what is necessary to accurately reflect medical management/decision-making and illustrate the importance of specific documentation. Appropriate selection of CDI staff, effective communication of the CDI program mission, appropriate metrics and C-suite support are essential for sustained success. As providers learn the goals of the program and query process, provider engagement increases.
In summary, Clinical Documentation programs can lead to improved quality scores, faster coding, higher case-mix indices, increased revenue capture and help with facility compliance. As one of the key areas of focus in the Mazars Revenue Cycle consulting services, CDI is driving higher reimbursement and improved CMI for clients across the US.
As a leading change facilitator in this era of sweeping health care reform, the Mazars Health Care Group offers health care payors and providers a powerful combination of service and results-oriented strategy to help them meet their business goals, overcome challenges, and improve performance. For more information about their timely, valuable information and insights into policies, best practices and industry developments, visit mazarsusa.com/hc.