How Far Does Your Facility Go for Documentation Assurance?

In Hospital Case Management’s recent article “Does Your Documentation Assurance Program Stop Short?” (March 1,2009), the following quote caught our eye:

“If your documentation assurance program focuses on reimbursement alone, you’re not going far enough. With pay-for-performance initiatives on the rise and increasing mandates for public reporting of hospital data, it’s critical that the medical record accurately reflect the severity of illness and the services provided to your patients.”

If we really think about it, the quote above is totally true. Many facilities have implemented Documentation Assurance Programs, such as Clinical Documentation Improvement initiatives. And these programs oftentimes measure ‘success’ in terms of dollars and cents, rather than by quality documentation of severity of illness, continuity of care, level of acuity and risk of mortality.

“Many times, documentation specialists do a great job of picking up the complications/comorbidities (CCs) and major complications/cormorbidities (MCCs) but stop right there and miss the opportunity to add additional documentation, which will affect the drivers of acuity level and risk of mortality.”

Documentation Specialists are trained professionals who are taught to look for those CCs and MCCs. In an attempt to build the best DRG, they must capture these important conditions. But, they shouldn’t just stop when they’ve gotten to a certain DRG level. A good Documentation Specialist will not be focused on getting the patient into the highest paying DRG, but will be focused on painting the most comprehensive picture of the health of each patient.

This is exactly where ComplyMD comes in. In attempt to paint the most vivid picture of (1) the health of the patient and (2) the procedure(s) performed on the patient, we aid physicians and staff in capturing the most documentation about each patient encounter. ComplyMD does not focus on CCs and MCCs, nor do we get involved at all with DRGs. We are focused on capturing complete and accurate documentation about each patient, to enable better patient care through knowledgeable patient information. With this comes data capture on severity of illness, continuity of care, level of acuity and the risk of mortality, with the bonus of MCCs, CCs and ultimately building an accurate DRG. We’re not focused on DRGs; we’re focused on enhancing patient care through comprehensive documentation.

Bert Amison of KPMG LLP said it well…

“So often, hospitals concentrate so much on reimbursement that they put other issues on the back burner. Many times, when we conduct an analysis of hospital documentation, we find little or no opportunity on the hospital reimbursement side, but there is a lot of opportunity on the risk-adjusted mortality side.”

His punchline bears repeating.  “There is a lot of opportunity on the risk-adjusted mortality side.” ComplyMD is just the right solution for capitalizing on this kind of opportunity within healthcare facilities.