There are seven characteristics that should be seen within clinical documentation for it to be recognized as high quality. The different healthcare reforms that have been introduced have only served to highlight how critical it is to ensure the maximum accuracy for all documents at all times. The outpatient setting can be even more diverse, including multiple care locations such as the emergency department (ED), hospital observation care, physician clinics, home health services, and ambulatory surgery. Standard of Care. 1991) (holding that information is not considered publically disclosed if “the communication does not release the information into the public domain such that is accessible to the general population.”). publication of the American Health A characteristic of high-quality clinical documentation is documentation that is precise. 67, 12 Stat. Clear Up Confusion with Routine Checks for Quality Control. Reason 7: RAC and Other Audits Inpatient care is reserved for a higher intensity of care that is delivered in a hospital setting while outpatient care requires a lower level of intensity and may be delivered either within or outside of a hospital. The Board’s oversight duties do not end with the initial administration of a license, but rather continues as long as a physician or other health care professional (Physician Assistant or Nurse Practitioner) continue to practice. Reduces risk management exposure. Sometimes patients will be at one location for their care and the documentation is the anchor that provides the information needed for the healthcare teams to stay on course. David Newton, a Clinical Documentation Manager, and Michelle Brooks, a Corporate Director of Case Management in Clinical Documentation Improvement (CDI) at Baptist Health Care, discuss the importance of accurate and timely clinical documentation and how they have seen CDI transform hospital and patient outcomes. Section 456.057(14), Florida Statutes.”. A good clinical documentation improvement program can not only make life easier for the billing department, but also for the patients themselves. Second, because of the revenue a particular physician is generating, his/her disregard for completeness and/or timeliness of clinical documentation is “overlooked.” By not addressing these issues, both the hospitals and physicians are taking significant risks. Professional association standards, such as those set forth by the American Academy of Orthopaedic Surgeons (AAOS) are often relied upon and incorporated into the healthcare providers guidelines. Tammy Combs (Tammy.Combs@ahima.org) is director, HIM practice excellence, CDI/nurse planner, at AHIMA. 696; 31 U.S.C. CDI is a process typically used in hospitals that employs specialists who review clinical documents and provide feedback to physicians, says Mark Morsch, vice president of technology at OptumInsight. [xi], Reason 5: Public Notice of State Medical Board Disciplinary Actions And the importance of complete, accurate, concise, timed and dated documentation cannot be overstated. Medical Boards publically release the findings of disciplinary hearings and can order an administrative penalty for failure to meet the standard of care for not maintaining adequate medical records.[xii]. [i] “These guidelines can take the form of federal or state statutory or regulatory requirements, professional association and accreditation standards, and health care organization internal policies, protocols and procedures.”[ii] Failure to conform to an established protocol, may, standing alone, constitute enough evidence that the healthcare provider breached the standard of care. Undocumented or poorly documented information relies on memory and is less likely to be communicated and retained. Your email address will not be published. … Inpatient hospital care. [v] HealthGrades, available at http://www.healthgrades.com/directory_search/physician/profiles/dr-md-reports/dr-jeffrey-heitkamp-md-2373f5dd/sanctions. These DRGs have relative weights that capture the complexity of care and are used for reimbursement purposes. Failure to keep adequate medical records (12/12/08), Issued To: Dr. Jeffrey Wade Heitkamp; License # F4064, State: Texas, Nature of Complaint: The physician failed to adequately document a complete examination and history that would justify surgical intervention in a patient with back and leg pain or discussions of alternatives to surgery. This information is needed to recognize the return on investment when developing and managing a CDI program. Up to 70% of nurses surveyed stated they were unable to find an indication in the medical record for a treatment they were administering to the patient. 1-866-670-0767 [xi] 31 U.S.C. [xv] 31 U.S.C. Documentation is critical for patient care, not only because it validates the care that was provided, but also because it shares key data with subsequent caregivers and optimizes claims processing. Clinical documentation integrity (CDI) is a profession that has, in the past, been viewed as just a revenue-seeking program—but that’s not the full story. Medical records are a crucial form of communication. Complete documentation is that which includes maximum content; reliable documentation is trustworthy and safe.5. Your email address will not be published. Overall, it is imperative for hospitals and physicians to collaborate in relation to appropriate and timely clinical documentation. Accurate and timely clinical documentation by physicians has always been the cornerstone of quality patient care and reimbursement. [ii] Ronald W. Scott, Legal Aspects of Documenting Patient Care, p. 163 (2nd ed. §§ 3729–3733, also called the "Lincoln Law. The impact seen throughout the different settings will vary. In healthcare, over the past 25-30 years we’ve seen the use, need, and importance of clinical documentation and coding greatly increase. [xiv] Target areas for auditors include: DRG assignment, medical necessity, contractor approved issues, and procedures unrelated to the primary diagnosis. 3731(c), 3732(a)(1), and 3729(a)(2), (a)(1)(B). issues that affect the accuracy, Continuing with the CHF diagnosis example, CHF is a chronic condition that can influence many aspects of a patient’s care. The benefits surrounding its success internationally include improved quality and … The new provider will rely on the documentation from the previous encounter to guide their medical decision-making. Principles Of Documentation In Health Care Settings. [xiv] CMS, Statement of Work for the Recovery Audit Contractor Program, https://www.cms.gov/RAC/downloads/Final%20RAC%20SOW.pdf (last visited Mar. Given the complexity of health care and the fluidity of clinical teams, healthcare records are one of the most important information sources available to clinicians. By not documenting, opportunities to capture CCs and MCCs are lost. §§1396a(a)(42)(B) and 1395ddd(h). These characteristics include documentation that is:2. Likewise, comprehensive, accurate documentation is important to all stakeholders in health care, from patients to providers, payers to researchers. [vi] American Academy of Orthopaedic Surgeons, Code of Ethics and Professionalism for Orthopaedic Surgeons – General Principles of Care, §VII(B)(D) available at www.aaos.org; Benson & Benson OB/GYN Center v. St. Josephs Regional Health Center, (2007 WL7120757, 1 (S.D. Sometimes, inadequacy equates to no history and physical or progress notes. As the delivery of health care and reimbursement methodologies evolve, the importance of a holistic clinical documentation improvement program becomes evident. Clinical Documentation Improvement (CDI) is a process to facilitate an accurate representation of healthcare provided through complete and precise reporting of diagnoses, comorbidities, and procedures to ensure the acuity and complexity of the patient is available to be coded. In addition to fines and penalties physicians and hospitals may be required to pay if claims were submitted without adequate documentation, medical errors were made, False Claims Act violations, or a licensing board or Joint Commission imposes a fine, there are other areas that are impacted. Californian Sentenced to Prison for HIPAA Violation, Information Blocking Implementation Roadmap, HIM’s How to Thrive Guide: COVID-19 Challenges Met, Lessons Learned and Advice to Forge Ahead, Information Blocking and HIPAA: Road to Compliance, Accurate Provider Data Governance Essential for Patient Care, Why Hospitals Need to Rethink Privacy and Information Security Models, Working from Home During COVID-19: Challenges and Solutions, AHIMA Webinar Addresses COVID-19 Medical Record Documentation Challenges. Requirements of clinical documentation and accuracy of data are essential in achieving quality and cost-saving outcomes, regardless of place of service or health care setting. This is a good example of a time when documentation may impact the patient’s disease burden representation in one setting but not another. For example, in the inpatient setting some payers will classify diagnoses into diagnosis related groups (DRGs). The legal standard of care or the required practice standards in a given situation, form the basis of a legal claim, which is often a state negligence or deceptive trade practice claim, or a component of a federal claim such as the Anti-kickback or False Claims statutes. CDI professionals should be aware of the impact of clinical documentation across the continuum of care. Initially created in 1863, the False Claims Act (FCA) enables the federal government to combat waste, fraud and abuse against those who are reckless, deliberately ignorant, or knowingly make false representations to the government. In today’s healthcare landscape, clinical documentation is the lifeblood of an organization. CDI programs that promote high-quality documentation not only support the capture of appropriate reimbursement but also the quality of care provided to the patient by ensuring all the information within the health record is of high quality and supports informed medical decision-making. Dr Samer A Kanaan | Thoracic Surgeon Irvine | Mission Viejo CA Information Management The inpatient setting can be broken into different hospital units based on the patient’s diagnosis or procedure that was performed. In relation to clinical documentation, hospital executives, employees and fellow medical staff members often express two scenarios. Clinical documentation is used to facilitate inter-provider communication, allow evidence-based healthcare systems to automate decisions, provide evidence for legal records and create patient registry functions so public health agencies can manage and research large patient populations more efficiently. The importance of high-quality clinical documentation across the continuum of healthcare can be recognized in the analogy of a cruise. (2000). Within each of the areas there are various care-focused groups. The benefits of clinical documentation improvement. Required fields are marked *, © Copyright AHIMA 2020. Group, 318 F.3d 1199, 1214 (10th Cir. [xii] Texas Medical Board, www.tmb.state.tx.us (Feb. 17, 2010). Therefore, the top seven reasons clinical documentation is more important now than ever are: (1) establishes the standard of care; (2) impacts physician state licensing; (3) basis of hospital/medical staff bylaws and Joint Commission accreditation; (4) implicates the False Claims Act for improper billing; (5) public notice of inadequate medical record maintenance by state boards; (6) adverse financial consequences for the physician and hospital; and (7) increased negative outcomes in relation to RAC audits. Clinical documentation improvement specialists are trained to have a firm grasp the clinical details of high-quality care and to be able to spot gaps in electronic health record charting. The importance of high-quality clinical documentation across the continuum of healthcare can be recognized in the analogy of a cruise. Even though CMI and the risk adjustment score are two different measurements, they both reflect the patient’s disease burden. If the outpatient CDI professional focuses on recognizing high-quality documentation and not just elements needed for HCC capture, they can better validate when all documentation meets the characteristic to be of high-quality, which would then accurately represent the disease burden across all settings. #F0861, Houston, TX – On February 5, 2010, the Board and Dr. Bacon entered into an agreed order requiring Dr. Bacon to pay an administrative penalty…within 90 days. Just as patients rely on numerous providers and healthcare professionals to maintain a good state of health, passengers on a cruise ship rely on numerous crew members to ensure they have smooth sailing and stay on course. Example: “Bacon, Robert J., Jr., MD, Lic. The anchor on a cruise ship can hold the ship in a certain location or be raised when the ship is sailing. rel Burns v. A.D. Roe Co., 186 F.3d 717, 722 (6th Cir. 20, 2011). Clinical documentation and coding are similar, as they are also the supportive building blocks in healthcare and can be thought of as foundational as well. The Board’s action was based on Dr. Bacon’s failure to meet the standard of care and maintain adequate medical records.”. Four Reasons to Document Properly 1. Health Information Trends: The Importance of Clinical Documentation Improvement By Megan Ruesink on 11/21/2016 As an aspiring professional in the heath information technology/management (HIT/HIM) field, you know that accuracy and integrity are of the upmost importance in your work. Association—delivers best practices in Furthermore, a hospital may request a survey that can be used both by a hospital for an internal review and a court.[vi]. Documentation communicates the quality of clinical care that providers... 2. The top audit trigger is improper or inaccurate billing. 1985). Medical staff bylaws, hospital bylaws and Joint Commission standards set parameters that promote and ensure quality patient care. It’s the job of HIM professionals to find all the pieces and assemble them to illustrate the full picture of a patient’s care. The elements within the documentation that impact the CMI and risk adjustment will vary. In order to avoid having to pay back previously reimbursed claims plus interest or going through a lengthy appeals process, better documentation decreases RAC findings. Investigation of complaints, hearings and disciplinary sanctions are all within the purview of the board. https://www.medicare.gov/coverage/inpatient-hospital-care, https://www.hopkinsmedicine.org/health/conditions-and-diseases/congestive-heart-failure-prevention-treatment-and-research. However, this should not lead the CDI professional to silo their health record reviews into only clarifying for documentation elements that impact reimbursement, but rather focus on high-quality documentation that accurately tells the patient story. A CDI professional should be aware of all the elements of high-quality clinical documentation so the patient’s disease burden is accurately captured in all healthcare settings. All Rights Reserved. [iii] A physician’s license may be revoked or suspended for failing to keep proper medical records. When patients are discharged or complete a provider visit, they may see another provider in a separate location and setting. The clinical documentation in the health record must support the presence of all patient condition/diagnoses, along with the provider’s assessment and plan for management of each condition, especially chronic conditions. In the outpatient setting the documentation of CHF is enough information for the condition to fall into an HCC. The physician's three surgeries on a patient contributed to the patient's final condition of disability. [iv] In turn, this negatively impacts a physician’s HealthGrades score. High-quality documentation is also vital to medical decision-making. The significant role CDI plays in healthcare has become apparent with the transition from the inpatient to the outpatient environment and from a financial to a quality focus. Congestive Heart Failure: Prevention, Treatment and Research. 2003); Ex. Improve Clinical Documentation Quality, Improve Health Care Patients flow through numerous care settings within the vast healthcare matrix, including inpatient and outpatient areas. The Golden Thread is the documentation that supports each decision, intervention, or client note that contributes to a complete record of client care that is error free and ready for reimbursement. During the course of an audit, Recovery Audit Contractors (RACs) are required to relay suspected fraud to the government. patient health information. Clinical Documentation Improvement in healthcare is important not only because proper documentation is a major component of the hospital’s reimbursement, but also because quality documentation leads to great relationships with other providers within and outside of a health system. Reason 1: Standard of Care The legal standard of care or the required practice standards in a given situation, … Moreover, Rule 64B8-9.003, Florida Administrative Code, in addition to the above, mandates that the records be legible and contain sufficient information to "identify the patient, support the diagnosis, justify the treatment and document the course and results of treatment accurately..." Finally, the physician should be aware that failure to keep written medical records could subject the physician to penalties ranging from a mere reprimand to a combination of a two-year suspension, followed by probation and a $5,000 fine. [x] The caveat is that the information cannot be publically available information. Aside from an adverse patient outcome, there are numerous ways that healthcare providers are subject to adverse legal, financial, and publicity in relation to clinical documentation. A... 3. The treatment of CHF is decided based on the type of heart failure and if the patient has any other underlying conditions.4 The documentation of underlying conditions would be considered complete and reliable documentation. All Rights Reserved. For patients, documentation ensures the delivery of safe, consistent, quality healthcare. Reason 2: Physician Licensing The setting in which a patient receives care is determined by the patient’s physician.1. The quality of medical documentation has several far-reaching impacts, from directly affecting the quality of patient care, to influencing hospital funding. Improved Outcomes. Second, if a condition is not documented as present on the first admission and is included in the Hospital-Acquired Conditions list set forth by CMS, if a patient is readmitted for an item on the list, then the healthcare provider does not get reimbursed.[xiii]. 1999); U.S. ex rel Hagood v. Sonoma County Water Agency, 929 F.2d 1416, 1419 (9th Cir. JOURNAL of AHIMA—the official The Importance of High-Quality Clinical Documentation Across the Healthcare Continuum. [iv] Pinellas County Medical Association, available at http://www.pinellascma.org/medrecords.html. §§ 3730(b)(2)-(4) (1986). [v], Reason 3: Hospital/Medical Staff Bylaws and Joint Commission Standards Just as patients rely on numerous providers and healthcare professionals to maintain a good state of health, passengers on a cruise ship rely on numerous crew members to ensure they have smooth sailing and stay on course. [ix] 42 U.S.C. With FERA amending the FCA, a new basis for liability emerged – knowing retention of an overpayment, regardless of the cause of overpayment. keeps readers current on emerging Healthcare professionals rely on the accuracy of correct... Beware the Snowball Effect. For a healthcare provider or an RCM stakeholder, the importance of clinical documentation improvement (CDI) cannot be emphasized enough. Clinical documentation improvement (CDI) is a recent initiative gaining increased momentum in Australia. Poor clinical documentation is undermining patient care, hospital sustainability and healthcare data integrity The care of all Australians is significantly impacted by poor clinical documentation. There are also a myriad of other reasons that a comprehensive medical record, that includes a detailed history and physical, progress notes, and consults, is vital. [viii] 31 U.S.C. [vii] The financial penalties are significant and enable the government to be awarded treble damages plus civil penalties ($5,000-$11,500 per claim). Incomplete or missing subjective, objective, assessment, and plan (“SOAP”) notes have the potential to adversely impact the physician and the hospital from legal, financial, and reputational standpoints. In the outpatient setting some payers will classify diseases into hierarchical condition categories (HCCs); these also have weights associated with them, which can be used to calculate a risk adjustment score. With this assortment of care settings, it would be detrimental to the patient if a provider only considered the care that was provided in one setting to guide their medical decision-making. Reason 4: The False Claims Act Careers   |   Legal Notice   |   Site Map, Reason 3: Hospital/Medical Staff Bylaws and Joint Commission Standards, Reason 5: Public Notice of State Medical Board Disciplinary Actions, Healthcare Compliance Advisors and Featured Staff, The Model Matters: Clinical Documentation Program Comparison, The Top Seven Reasons Clinical Documentation Is More Important Now Than Ever, Double Dipping is Proper Etiquette for Medicare and Medicaid Auditor Contractors", Lost in Translation: Bridging the Language Gap Between ICD-9 and ICD-10, http://dpr.delaware.gov/boards/medicalpractice/index.shtml, http://www.pinellascma.org/medrecords.html, http://www.healthgrades.com/directory_search/physician/profiles/dr-md-reports/dr-jeffrey-heitkamp-md-2373f5dd/sanctions, https://www.cms.gov/hospitalacqcond/06_hospital-acquired_conditions.asp, https://www.cms.gov/RAC/downloads/Final%20RAC%20SOW.pdf. health information management and ", Copyright © 2011-2020 BCE Healthcare Advisors. Since 2009, two important laws, Fraud Enforcement and Recovery Act of 2009 (“FERA”)[viii] and the Affordable Care Act of 2010 (“ACA”)[ix] expanded whistleblowers’ protections and their ability to bring FCA suits. Documentation plays a critical role in communicating to third-party payers the need for evaluation and treatment services (medical necessity) and why those services require the skill of the speech-language pathologist (SLP). First, coders cannot rely upon items absent from the record. October 06, 2017 - Clinical documentation improvement (CDI) is the process of enhancing medical data collection to maximize claims reimbursement revenue and improve care quality.. Each episode of care should include documentation that clearly supports each episode of care. Action Taken: The physician has entered into an Agreed Order with the board for a period of two years subject to the following terms and conditions: The physician's practice shall be monitored by a board designated physician monitor who shall review selected patient medical and billing records. Clinical Documentation Improvement and Social Determinants of Health The Clinical Documentation Improvement (CDI) profession continues to evolve as its importance strengthens. Documentation is an essential component of effective communication. Importance of Medical Documentation Basic Documentation. Clinical documentation must incorporate the concept of the “Golden Thread”. Reason 6: Adverse Financial Consequences Communicates with other health care personnel. The premise of CDI is simple: engage clinicians to improve the clinical documentation in the medical record in "real time" so that it is fit for reporting, analysis and reimbursement. Because RAC auditors can also file a qui tam suit, there is an additional incentive. It is vital for CDI professionals to be aware of the documentation elements that have an impact in the setting in which they work. While payment may not be the focus when providing healthcare, good documentation remains an arguably strong link to financial performance, which subsequently impacts the ability to continue to provide healthcare services. rel Holmes v. Consumer Ins. Documentation is often the sole point of communication between nurses of changing shifts. Documentation mitigates risks and reduces the chance of malpractice. Who Has Rights to a Deceased Patient’s Records? “According to Section 458.331(1)(m), Florida Statutes, a physician may be disciplined for "failing to keep written medical records justifying the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered, and reports of consultations and hospitalizations." Tex)) (relying on a survey report from the American College of Obstetrics and Gynecology to not renew physician’s privileges). US Centers for Medicare and Medicaid Services (CMS). The physician shall successfully complete eight hours each of continuing medical education in medical recordkeeping, risk management, and lumbar surgery complications and outcomes within two years. [xiii] Centers for Medicare and Medicaid, Hospital-Acquired Conditions, available at https://www.cms.gov/hospitalacqcond/06_hospital-acquired_conditions.asp; Deficit Reduction Act of 2005, §5001(c). Every country has differing healthcare systems and this article has focused on validating the relevancy of CDI for the Australian healthcare environment. The Importance Of Clinical Documentation Improvement According to The American Health Information Management Association (AHIMA), CDI is so important in the health care world because it has a direct impact on patient care.