The provider community has been begging for documentation reform for over 20 years, and there is no question that simplifying the complex requirements of clinical documentation is necessary. Unfortunately, the recent release of the proposed changes from CMS surrounding evaluation and management (E/M) is not the answer. The benefits of the modest reduction in documentation requirements are more than offset by the devastating impact the changes will have operationally, clinically, and financially.
Hayes' Healthcare Blog
Success has never felt so good. We have successfully met and surpassed the national ICD-10 implementation from October 1, 2015. If you were like most organizations, you were ready a year in advance. Others, however, were relieved when CMS postponed the original go-live date of October, 2014 to a year later. Some physicians have been very vocal about the challenges involved in learning a new coding system, and we continue to see growing pains as the new ICD-10 codes are implemented. With reimbursements in full swing, how do you ensure your organization is successfully and efficiently implementing all these changes?
One way you can ensure this is by creating, implementing and optimizing an official audit process.
Picture a road race with no finish line. I envision it would look similar to the bewildered faces of patients leaving your office without stopping at a checkout desk. Without closure from their appointment, your patients may have trouble explaining details to their loved ones when they get home or have likely forgotten the next steps. They may have the clinical summary printout in their hand, but closing the patient’s appointment is more than providing a list of instructions and showing them the door.
While ICD-10 migration can sometimes feel like a test to be graded, it’s more of a process to embrace in the name of better patient care. The ICD-10 deadline, despite its delay, is rapidly approaching and with it comes a number enterprise-wide changes. These changes, of course, include your clinical documentation - otherwise known as the key source of patient services. It also communicates why the patient in there in the first place. Clinical documentation affects three key parts of your organization: patient care, healthcare data and reimbursement. How can your organization harness clinical documentation improvement (CDI) to ensure optimization of ICD-10 utilization? We have six recommendations to consider.
Implementing a clinical documentation improvement (CDI) initiative for outpatient settings is a crucial element of ensuring your coding is accurate and your claims are billable. CDI drives what can be coded and billed; it ensures descriptions of patient encounters, assessments, treatment planning and dates of service in the clinical note are correct.
Traditionally, when we discuss clinical documentation improvement efforts and resources; the focus has been primarily allocated for inpatient services. However, the Accountable Care Act (ACA) and the Institute for Healthcare Improvement (IHI) are encouraging medical communities to broaden the scope of reach to include outpatient settings. The quality of patient care and value of services rendered is determined by the comprehensiveness of the clinical encounter note and treatment outcomes.
In a recent survey, more than 270 hospitals were asked if they had an active clinical documentation improvement (CDI) program; 66% said yes, while 34% were in the discussion and assessment phase of determining where to begin, cost and value of establishing a formal CDI program. Statistics indicate that significant increases in reimbursements and revenue gains as a direct result of implementing a CDI platform.
So how do you fast track your organization to CDI excellence?