The manager should collaborate with hospital departments to review their documentation practices and identify opportunities for improvement through technology. There has been much discussion and confusion regarding the use of information from prior encounters in a current clinical documentation query. Check that E/M leveling narrates the true nature of the visit: Typical EHRs use boilerplate documentation templates with general canned statements geared toward hitting the documentation requirements for an evaluation and management (E/M) level four office visit, regardless of the nature of the presenting problem. 2. “The model has been to allow more customization in terms of documentation templates and less standardization around what are the best practices for a particular clinical … Create a culture that values data accuracy and implement educational opportunities that provide employees with the skills to operate a high performing clinical documentation improvement program. While many large healthcare facilities have invested in automated systems to improve clinical note taking, there are a number of things that the smaller practices can follow to ensure best and accurate clinical documentation. Similar to the paper written note, where the relevant clinical historical components are summarized, these narratives will present an individualized patient-specific chart note and further prevent the physician’s notes from looking the same from patient to patient. Clinical documentation improvement (CDI) is a process that continually seeks to answer, “How best can we maximize the integrity of the medical record?” Although the goal of CDI is always the same — to provide a complete and accurate picture of a patient’s medical condition(s) and the care they receive — the means to achieve that goal are often specific to the setting (e.g., office versus facility). 3. The primary evidence is the Form CMS-2567, and any other documentation used to make the determination of survey results (e.g., surveyor notes). The following Touro University California documentation guidelines, supported by institutional review board-approved research and engagement with current medical student training, are offered as a best-practice approach to health record documentation training as we approach and engage 2021: Health records must contain accurate information. Research. The ALJ relies on the testimony of witnesses and the documentation from the survey in making a decision. The primary focus of CDI for physicians in an office environment is to convey effectively, through documentation, a provider’s thought process regarding patient care. There are many tools and publications to assist providers in improving their clinical documentation such as AAPC’s auditing software and services and Healthicity Healthcare Auditing Services. Clinical Documentation Improvement Program. Facilities should encourage providers to tailor documentation to capture clinical aspects, as well as co-morbidities, quality measure specifications, etc. Astara N. Crews, MJ, BS, CHC, CPC, has over 20 years of experience in coding, auditing, compliance, and corporate governance. To avoid the shortcomings of point-and-click or auto-generated text, ask providers to add their own narrative to the record. For example, what appears to be a normal heart rate to one specialist may signify something else to a cardiologist. Clinical documentation improvement is a prevailing topic in the health care industry. Clinical documentation is the catalyst for coding, billing, and auditing, and is the con-duit for (and provides evidence of) the quality and conti-nuity of patient care. As it is, according to the requirements of Stage 2 Meaningful Use, allowing patients access to their medical records is mandatory – why wait to implement the same. We are looking for thought leaders to contribute content to AAPC’s Knowledge Center. Best Practices in the Art and Science of Clinical Documentation Improvement. With detailed, accurate documentation, clinical analytics can assist in improving the decision-making process and help catch the development of complications before they begin. Unless the care is maintenance or supportive care, develop an individual treatment plan for each patient. Copyright © MedConverge 2021 — All rights reserved. Your staff may be familiar with documentation standards, but in this rapidly changing healthcare environment, it is important that they upgrade themselves regularly. As of April 1, 2018, we have used the toolkits at 4346 initial patient visits. Her department provides coding and documentation education and training for physicians and clinical support staff. Assign CPT ® and/or HCPCS codes. Indicate the impact on reimbursement, payment methodology, or quality metrics. The purpose of this Practice Brief is to describe documentation best practices and serve as a resource in effective and efficient clinical documentation practices without having a negative impact on patient care. documentation practice, these documentation guidelines encourage employers, medical record and clinical staff to incorporate strategies, policies and procedures that strengthen effective documentation practices within the work setting. All healthcare facilities – irrespective of whether they are a business enterprise or a charitable institution – have to be financially viable in order to continue to provide services. The facility also needs to analyze these results to find out which physicians are queried most often and which diagnosis is queried the maximum – there may be a need for further education/training for physicians / coders. Plan differently. Crews is a member of the American Health Lawyers Association and Healthcare Compliance Association and serves as president of the Lower Westchester, N.Y., local chapter. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance Portability and … The author identifies the key users of clinical documentation from patients to clinicians to coding professionals to reimbursement entities and throughout the … Best practices require that a CDI physician advisor, often a hospitalist, support the CDI program. This version is made available for historical purposes only. Clinical documentation improvement (CDI) tools can help healthcare organizations accurately represent information about patient health events, clinical status, and office visits in … Unlike a traditional clinical documentation improvement specialist, the documentation quality manager is responsible for improving the technical component of documentation and coding. Having a Compliance Plan to ensure there is accountability for all BHRS, Community Programs activities and functions. Even one or two lines from the provider add detail and integrity to the note by answering all-important questions such as “How is this note unique?” or “What is unique to this patient at this visit?”. Communicate with the coding/HIM staff to resolve discrepancies between the working and final DRGs. Providers should think about what they would have included in the documentation that they can add to the EHR. In the facility setting, collaboration is both more readily available and vital to ongoing success. All documentation used at the hearing becomes part of the public record. Clinical Documentation Standards . According to the American College of Physicians, practices should define guidelines based on “consensus-driven professional standards unique to individual specialties.”. Communicate with coding/HIM staff to resolve discrepancies in … Similarly, if aspects of a patient’s medical history play a role in the physician’s decision-making, a summary of that history and how it affects treatment options should be included. examination. Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. The advisor is the core of the program – someone who is there to answer questions from other physicians and support staff. Communicate effectively: In facility documentation, there are generally multiple clinicians contributing to the same record to determine a root cause of the patient’s condition. Making use of technology, to allow patients to review their medical records on an online portal can and will help the facility to improve the accuracy of its documentation. The benefit of an EHR is that the system provides greater ease in reviewing historical information as it relates to another provider’s contributions. Essential for patient safety and care, quality ratings, accurate reimbursement and reduced physician queries, CDI programs are required and necessary for consistent and complete documentation. Insights and Best Practices for Clinical Documentation Improvement Programs In the face of alarming predictions about ICD-10’s administrative impact and its veritable explosion of new codes to wrangle with, and despite the proven positive impact on improving the accuracy of DRG assignment and quality metrics, some hospitals still It’s always best practice to supplement these templates with physician narrative free-typed text that speaks to the true nature of the visit. Create guidelines for best practice. Quite often historical clinical information is “pulled forward” to the current encounter, and the conditions present at the initial onset of the patient’s presentation to the facility no longer exist, yet the conditions or diagnoses remain in the active problem list. Take Away: Greatest level of specificity supports additional length of stay and increased resources required to care for the higher acuity patient Medicare Guidelines dictate specific words that must be present in order to choose and apply a code for billing. Such a awesome post catch my eyes & pulled me up to learn more about CDI, waiting for future posts. Strategies to maintain quality documentation practice include; Organisational Support By encouraging discussion and active learning, this interactive event prepares ... • Clinical Documentation Improvement: Quality Measures and If a specialist is documenting that a certain area (out of their scope of practice) is normal without expertise, there may be the off chance that a condition is overlooked. Join AAPC’s Author Panel - Be Recognized, Best Practices to Achieve Clinical Documentation Improvement, Focus on Coding 3 Common Pediatric Eye Conditions, Break the Cycle of Poor Physician Documentation, Achieving Clinical Documentation Improvement, 5 Ways to Improve CDI and Coder Collaboration, Documenting an all normal exam does not add any benefit to the care provided, especially when not necessary; and. It isn’t advisable for all collaborating clinicians to copy/paste the history, lab, and testing results from before because it makes it difficult for a reader (i.e., fellow clinician, auditor, or coder) to determine the current nature of the condition being treated versus repeat clinical care. Although the history and exam are typically somewhat standard, a brief description of the provider’s assessment and rationale will go a long way to support the plan of care and demonstrate medical necessity for provided services. The limited choices afforded by these tools do not always provide the details necessary to explain a patient’s condition or the provider work and decision-making that result in a treatment plan. December 2020 7 . As a contributor you will produce quality content for the business of healthcare, taking the Knowledge Center forward with your knowhow and expertise. In summary, a clinical documentation improvement program is a comprehensive, multi-disciplinary effort that includes the medical staff, clinical documentation specialists, inpatient coders, and CDI physician advisors. Here’s a quick rundown of best practices in each location. Editor’s Note: This Practice Brief has been updated. Providers must be able to communicate effectively with each other to avoid “note bloat.” Coded data is derived from clinical documentation provided during the patient encounter. Based on the chief complaint/clinical exam findings, establish specific treatment goals for each patient which are . Improve documentation by introducing best practices that reduce incomplete and lack of specificity in documentation; Lower clinical denial rates by providing ample clinical documentation to support diagnosis and withstand third party denial; Provide focused physician education by providing data showing specific trends The advisor needs to be enthusiastic about the program, complete knowledge of best documentation practices and a good role model. Healthcare entities that will fare the best under the new value-based system will have an integrated clinical documentation program in place that facilitates an accurate depiction of each patient’s level of care, symptoms, diagnoses, treatment, and outcomes. Earn CEUs and the respect of your peers. We have developed Best Practice Advisories (BPA) and other clinical documentation support tools that alert physicians, when appropriate. Improve clinical documentation and flag missing or incomplete charts in real-time for faster resolution. Often, multiple specialists are examining the patient to find root causes, and providers must communicate effectively with each other using the medical record. This policy section defines the procedures and minimum standards for documentation of Medicare/Medi-Cal Specialty Mental Health Services at any site providing those services within Alameda County Behavioral Health Care Services and its Behavioral Health Plan's Provider Network. Identify coding trends, growth, and gaps in diagnoses and procedures. The aim is to provide clarity and brevity while keeping the needs of other readers in mind. In order to enjoy the full benefits from ICD-10 and meaningful use, data collection techniques have to improve with healthcare providers looking at data collection as a comprehensive initiative to ensure effective and safe patient care. According to the American College of Physicians, practices should define guidelines based on “consensus-driven professional … There is generally no need to repeat the elements of the patient’s history that have already been established by another clinician. Encourage the provider to a specific diagnosis or procedure. The way in which each specialist contributes to patient care should be part of the documentation. best practices through real-life examples, exercises, and breakout sessions on specific clinical and coding topics. This Clinical Documentation Manual is to be used as a reference guide and is not a definitive single ... code of conduct and best-practice standards for billing and documentation • Participation by all providers in proactive training and quality improvement processes. With detailed, accurate documentation, clinical analytics can assist in improving the decision-making process and help catch the development of complications before they begin. Making mistakes is human and it is inevitable that physicians will make documentation errors at times. Each provider’s documentation should be tailored to capturing their clinical aspects and contributions, as well as co-morbidities, quality data, etc. By simply scrolling or clicking onscreen, the information is readily available. This improves overall patient care, as well as enhances risk management from a patient safety perspective, with fewer return visits to the office, shorter hospital stays, and increased quality scores. From a clinical documentation perspective, an initial presentation of a newly developed, undefined root cause evaluation may warrant a comprehensive review of potential findings. For example, auditing and coding departments may provide examples and education on how to maximize coding, billing, etc., through careful documentation. 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