Is your clinical documentation improvement (CDI) program identifying your outliers? [i][i] James v. Brown, 637 SW2d 914, 918 (Tex. §§ 3730(b)(2)-(4) (1986). 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 … The quality of clinical documentation assists in optimising the patient’s care. 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. Example: “Bacon, Robert J., Jr., MD, Lic. 1-866-670-0767 In healthcare, over the past 25-30 years we’ve seen the use, need, and importance of clinical documentation and coding greatly increase. The importance of good documentation practice needs to be emphasized to investigator sites to ensure that the study results are built on the foundation of credible and valid data. All Rights Reserved. Bottom Line: Regardless of what procedures the physician performs – and how mandatory or integral it is that the procedure be performed in line with the rest of the documented services – if a particular procedure is not documented, it does not get reimbursed. Medical record documentation is a cornerstone to achieving compliance and optimal patient care. [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. Objectives: 1.To demonstrate how the case note is used to provide program accountability 2.To demonstrate how the case note is used to indicate client progress 3.To reinforce the importance of timely, concise, accurate, standardized case notes as a “best practice” in … Clinical records provide uniformity and continuity across visits, hospitals, physicians, and … 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. 2018 Aug;122(8 ... nine post-EHR and two examined both periods. Section 456.057(14), Florida Statutes.”. 3731(c), 3732(a)(1), and 3729(a)(2), (a)(1)(B). 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. During the course of an audit, Recovery Audit Contractors (RACs) are required to relay suspected fraud to the government. 1985). Clinical records provide uniformity and continuity across visits, hospitals, physicians, and payer providers. [xi] 31 U.S.C. Does your documentation capture the level of ICD-10 coding specificity required to achieve optimal reimbursement? Sometimes, inadequacy equates to no history and physical or progress notes. In patient care organizations, proper and accurate clinical documentation has always been important, but in today’s shifting healthcare landscape, it has become even more of a strategic imperative than perhaps ever before. Providers are mandated by law and regulatory bodies to capture some form of record about an encounter with each patient. The capturing of all diagnoses that are relevant to the treatment, socioeconomic, and/or psychosocial circumstances are important to accurately capture the patient’s clinical picture and potential health hazards, therefore providers should be educated on the impact of these additional diagnoses. Clinical documentation improvement (CDI) roles are being increasingly created in Australian hospitals. 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. Clinical Documentation ICD-10 2. Proper documentation promotes safe patient care, good communication among staff members, and the advancement of the nursing profession. By not documenting, opportunities to capture CCs and MCCs are lost. The record allows the entire healthcare delivery team to provide quality patient care. For example, if a patient came in for an office visit for a cough and during the examination … 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. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services. Documentation communicates the quality of clinical care that providers are delivering to patients and serves as a means to facilitate the continuum of care, from EM to HM and beyond. The above factors are especially important with clinical documentation improvement (CDI). Clinical documentation implementation (CDI) programs can be beneficial in this transition. Reason 1: Standard of Care 20, 2011). Group, 318 F.3d 1199, 1214 (10th Cir. “Clinical documentation improvement and billing specialists help ensure hospitals, physician practices, and patients are correctly billed for … First, coders cannot rely upon items absent from the record. 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. Complete and accurate documentation validates the care provided shares key data with subsequent caregivers and allows coders to code accurately to ensure the hospital is fairly paid. Furthermore, since it is ultimately the physician’s responsibility to establish the cause and effect relationship of the disease process, a fully documented record provides him with the tools he needs to make that determination. [viii] 31 U.S.C. Medical notes are a vital means of communication between all those providing care to the patient and also of relevant communication with patients themselves and their relatives. Are Primary Care Coding Questions Slowing You Down? [vii] Act of March 2, 1863, ch. All Rights Reserved. Remember: Payers determine eligibility for payment through the documentation submitted to substantiate the claim. Documentation provides an electronic record (and usually also a hard copy). BACKGROUND: Radiology reporting is a clinically oriented form of documentation that reflects critical information for patients about their health care … [xv] Therefore, it is imperative that accurate documentation be provided in a timely manner. Find Out Which New Therapeutic Service Codes Made the Latest CCI Edit List. 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. Correct documentation is not only important for hospital reimbursement, but also for ensuring that patients’ bills are accurate as well. Increasingly, medical records are pivotal to medicolegal cases and litigation. 1999); U.S. ex rel Hagood v. Sonoma County Water Agency, 929 F.2d 1416, 1419 (9th Cir. Providers must be able to justify their claims with accurate, timely, and comprehensive clinical documentation. The anchor on a cruise ship can hold … 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. 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. 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. The physician's three surgeries on a patient contributed to the patient's final condition of disability. The success of CDI programs relies on a cooperative effort between physicians, health information management, coders, and clinical documentation specialists. Healthcare professionals rely on the accuracy of correct patient information to create and evaluate treatment plans and monitor patient healthcare over time. Good medical records document basic facts of patient care, including what was done by whom, and what results occurred, according to an outline from the New York State Society for Clinical Work, Inc. Compiling meaningful clinical details in one place supplements the medical practitioner's memory of crucial events that occur later in treatment. Good clinical documentation is a critical element in delivering patient care. Physician licensure is administered through individual state boards that have the duty of oversight and healthcare consumer protection. 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. Coders, how do you ask for documentation clarification? Are you clear on how to fix your coding and documentation shortfalls? Importance of Clinical documentation for accurate ICD-10 coding ICD-10 is not the coding but it’s improved Patient care which is documented Descriptive documentation to support accurate coding is the base of reimbursement from the insurances If physicians don't document … Clinical Documentation: Why is it so Important. §§1396a(a)(42)(B) and 1395ddd(h). Elizabeth 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. Tex)) (relying on a survey report from the American College of Obstetrics and Gynecology to not renew physician’s privileges). [vii] The financial penalties are significant and enable the government to be awarded treble damages plus civil penalties ($5,000-$11,500 per claim). UM Comprehensive AIDS Program. Pitfall: Once payers get involved, physicians could find themselves facing possible fraud and abuse charges – all based on a simple mistake or oversight that snowballed out of control. Documentation is an essential component of effective communication. 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. BMJ Open [online] 4(8): e005240 – e005240 . [xiv] CMS, Statement of Work for the Recovery Audit Contractor Program, https://www.cms.gov/RAC/downloads/Final%20RAC%20SOW.pdf (last visited Mar. §§ 3729–3733, also called the "Lincoln Law. [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). Professional documentation includes Any and all forms of documentation by a clinician recorded in a professional capacity in relation to the provision of patient care. Sonya O. Boyne, LMHC. 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. Good documentation is an important part of improving both patient care and nursing practice. Undocumented or poorly documented information relies on memory and is less likely to be communicated and retained. 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]. Undetected problems in medical records can fester, impacting everything that is later built upon that faulty information, including billing for services that may not have been provided. To find out more about the specific documentation standards where you practice, contact your state board of nursing. Reduces risk management exposure. These notes provide a baseline from which any provider can build, review, and follow up on treatment plans. 696; 31 U.S.C. The advantages of quality clinical data are well known among physicians and the practice of evidence-based medicine, and little doubt exists that CDI can increase hospital revenue.A Black Book Market Research report last year showed almost 90 percent of hospitals with 150 or more beds outsourcing clinical documentation functions made over 1.5 million in healthcare revenue and claims reimbursement after implementing CDI.Bla… With FERA amending the FCA, a new basis for liability emerged – knowing retention of an overpayment, regardless of the cause of overpayment. First, the documentation is inadequate and untimely. Investigation of complaints, hearings and disciplinary sanctions are all within the purview of the board. [xv] 31 U.S.C. “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." The quality of medical documentation has several far-reaching impacts, from directly affecting the quality of patient care, to influencing hospital funding. CDI programs may comprise coding and/or nursing specialists assisting physicians on documentation in order to allow for timely and accurate coding. 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. The importance of clinical documentation improvement for Australian hospitals Clinical documentation improvement (CDI) is a recent initiative gaining increased momentum in Australia. 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]. Important: From this record, physicians determine or modify treatment plans, chart disease progression, and craft an entire case history. Documentation queries may be helpful in clarifying diagnosis codes. 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. Because RAC auditors can also file a qui tam suit, there is an additional incentive. Documentation helps to inform and support providers by supplying information to highlight trends, providing insight into disease processes, and uniting physician teams and payers through the flow of data. The importance of high-quality clinical documentation across the continuum of healthcare can be recognized in the analogy of a cruise. Documentation provides a valuable account of a patient’s concerns, as described to the physician, and the physician’s assessment of, and findings about, the patient’s condition and resulting treatment plans. Furthermore, a hospital may request a survey that can be used both by a hospital for an internal review and a court.[vi]. You Can Only Bill What Has Been Documented. [2006] states, “the usefulness of abstracted data for quality and safety purposes relies on good documentation in the medical record”. Reason 6: Adverse Financial Consequences Devkaran, S, O’Farrell, P (2014) The impact of hospital accreditation on clinical documentation compliance: a life cycle explanation using interrupted time series analysis. 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.”). Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Reason 2: Physician Licensing [ii] Ronald W. Scott, Legal Aspects of Documenting Patient Care, p. 163 (2nd ed. [iv] In turn, this negatively impacts a physician’s HealthGrades score. (2000). Bottom Line: Documentation is the physician’s best weapon in his arsenal to maximize both patient care and payer reimbursement. Unfortunately, good documentation can become a low-priority for busy junior doctors. 1982); Lanier v. Sallas, 777 F.2d 321, 323 (5th Cir. [iv] Pinellas County Medical Association, available at http://www.pinellascma.org/medrecords.html. This item appears in the following Collection (s) Informatics Graduate Theses and PhD Dissertations Informatics School Theses and Dissertations It is important to understand what good clinical documentation is and who is responsible for it as well as what these roles potentially offer our health system. 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