Clinical Documentation Improvement at the Frontline of Evolving Healthcare

Clinical Documentation Improvement (CDI) has helped healthcare organizations leverage medical data to enhance care quality and maximize claim reimbursement revenue. However, one of the lesser talked about aspects of CDI is how it helps hospitals develop relationships with service providers outside the hospital walls.

As healthcare transitions towards leveraging systems that ensure the quality of care and interoperability, CDI programs will play a critical role in consolidating the information from inpatient and outpatient care and providing patients with complete, accurate, real-time documentation of their conditions. This is just one of the several ways that CDI can streamline care delivery and provide hospitals with greater control over patient information.

Increased usage of documentation and coding for care quality assessment and reimbursement across healthcare will only compel non-acute care facilities such as home health, inpatient rehab facilities (IRFs), and so on to also adopt CDI programs. Complying with payment reform policies introduced by the CHIP Reauthorization Act (MACRA), hierarchical condition coding (HCC), risk adjustment scores, value-based purchasing, and ICD-10 requires every entity leveraging CDI programs to closely focus on correct and accurate documentation.

The Repercussions of Coding Errors and Inadequate Documentation

The growing importance and complexity of the documentation process have also caused healthcare organizations to deal with a documentation burden. This has often been cited as a reason for inaccurate and inadequate documentation. In a value-based care model, this could result in poor patient care, incorrect billing, and reimbursement issues.

The documentation framework needs to capture the details of the care delivery consistently and accurately. A simple mistake during the care authorization process can indicate a completely different diagnosis. This could lead to unnecessary tests and result in delays and even denial in service. In the worst-case scenario, the consequence of such an error could irreparably damage the relationship between patients and care providers. Inaccuracies in the documentation can adversely affect patients’ experiences outside the office and cause subsequent reputational damage.

Moreover, inaccuracies in the documentation could lead to coding errors and claim denials. A 2018 CMS report revealed that insufficient documentation led to a national revenue loss of $17,759 million.

Care providers and hospitals with a history of coding errors and inadequate documentation may end up facing federal sanctions and penalties for medical abuse. Failure to rectify documentation errors could lead to coding and billing redundancies that can be deemed as a case of fraudulent medical representation. In fact, as a violation of the Federal Civil False Claims Acts (FCA), a hospital can end up incurring penalties that are equal to, if not more than, three times the value of the false claim. Besides dealing with legal and settlement fines, medical abuse charges can also lead to the cancellation of the provider’s license.

Another consequence of documentation errors is their impact on patient-related studies. Researchers often rely on medical records and documentation from hospitals and clinics to conduct patient-related studies. In turn, these studies can help healthcare organizations identify gaps in the existing practices and even opportunities to introduce new services. However, inaccurate documentation could lead to failed observations and false insights. Consequently, this could deprive the healthcare industry of helpful insights to improve care and enhance service and revenue models.

The Need for an Effective Documentation Framework and Claim Validation Strategy

Clinical documentation improvement is the first step towards preventing claim denials and recoupments. One of the primary aspects that healthcare organizations need to ensure is a strong people core. This involves focusing on building a team of capable CDI specialists.

CDI specialists play an important role in preventing documentation errors and improving value-based care key performance indicators (KPIs) such as the severity of illness and rate of mortality (SOI/ROM), case-mix index (CMI), and discharged not finally coded (DNFC) days.

This, in turn, can help hospitals improve their diagnosis-related group (DRG) based reimbursements and significantly enhance the quality of patient care. In fact, according to a 2016 survey, almost 90% of hospitals that employed CDI specialists earned over $1.5 million more through reimbursements and healthcare revenue.

The next most important aspect of establishing a strong CDI program is to engage coding experts in a robust documentation auditing process. With retrospective documentation auditing, healthcare providers can review errors that potentially harm the hospital's revenue or patient care quality. The audit process plays a crucial role in helping organizations thoroughly monitor clinical documentation, coding, and other billing processes. It can allow providers to assess their internal documentation processes and identify high-risk areas and underlying issues based on historical data on failed documentation. Hospitals can also consider training a senior coder for clinical documentation auditing. This will enable holistic inside-out visibility of the documentation process and the subsequent coding quality.

While revisiting the documentation framework can solve most problems, the dependency on humans for routine tasks still leaves some room for error. To address all the challenges effectively, providers will have to consider implementing AI-enabled computer-assisted coding (CAC) and computer-assisted CDI (CACDI). In the next blog of the series, we will explore how AI technology can play an intrinsic role in transforming the way healthcare organizations approach coding and documentation.

Partnering for Success.

Whether it is about creating a robust claim validation strategy or leveraging technology to fortify documentation and coding processes, healthcare organizations need to have the right technology implementation roadmap to create long-term value. And it is here that an experienced technology partner like EZDI can help create a difference.

As the only fully integrated, born-in-the-cloud, AI-enabled technology provider, EZDI’s repository of advanced CAC solutions can allow healthcare institutions to help prevent denials, increase revenue and bolster claims reimbursement processes.

To learn more about how healthcare organizations can streamline clinical documentation in the new normal, read our eBook here. — https://www.ezdi.com/ebook-clinical-coding-in-the-new-normal/

Originally published at https://www.ezdi.com.