Better Documentation – Why It’s So Crucial

A great article by Selena Chavis in For The Record magazine, gives us all a little insight into WHY documentation is so important. A few of the summarized reasons include:
• Quality of patient care
• Patient safety and outcomes
• Compliance
• Revenue cycle management

So we see that documentation doesn’t just affect compliance and revenue cycle management….it extends all the way to patient safety and quality of care. Think about it: Of course better documentation would give you a better picture of what’s really going on with your patient, thus you are able to make better decisions for their course of care.

Chief privacy officer and executive director with Georgia-based Wellstar Health System, Beth Kost-Woodrow says, “[Better documentation is] the one piece that sets the stage for success or failure in many areas of hospital operations and patient care.” I believe she is right. Better documentation not only affects the facility, but the physician as well. “As hospital and physician profiling on the Internet has increased scrutiny, many experts suggest that attitudes are changing and the time may be ripe for a renewed focus on documentation improvement programs.”

American Healthcare – Where Data (Should Be) King

First of all, let me state the obvious. I do not believe that data capture and data analysis should take any form of precedence over quality patient care. This posting is to point out the fact that better data (analyzed data, that is) can improve patient care, even to the point of saving lives. I love this point from the article: “A health care system that is driven by robust comparative clinical evidence will save lives and money.”   

 

So, let’s again visit the great New York Times article about Baseball & American Health Care to find more information about data and documentation within the American health care system.  We see hints all throughout the article about data, data, data……more data (analyzed data) enables better evidence-based methods. We’ve seen the vast improvement in baseball because of their data-driven research and statistics. And we also are able to catch a glimpse of the deficiency of data-driven research and statistics within the American health care system.

 

“Remarkably, a doctor today can get more data on the starting third baseman on his fantasy baseball team than on the effectiveness of life-and-death medical procedures. Studies have shown that most health care is not based on clinical studies of what works best and what does not –be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition.”

 

Overcoding, Undercoding and Inadequate Documentation – How Can They Be Avoided?

In response to the question “What percentage of physicians, in your experience, exhibit overcoding or undercoding patterns?”, John W. McDaniel answers:

“We work with hundreds of physician practices each year, and probably 80% of all the doctors with whom we work undercode. About 15% overcode, and about 5% code accurately. Even those that seem to overcode may not in fact be overcoding, because chart audits will reveal that the real underlying problem is inadequate documentation to support the appropriate code.”

Physician Practice Options, September 2000. “Practice Management Expert Highlights the Importance of Coding Compliance”

 

As we can see, a look into a physician practice’s coding records will reveal a lot about the actual accuracy of their coding. Now, please note that this does not say “coders are doing a poor job of coding” – by no means is this laying the issue on the coders shoulders. What this reveals is that physicians are the ones who are doing a poor job of documenting. Inadequate documentation is a huge issue. Erroneous documentation is another no-no. LATE documentation can even cause issues and discrepancies in a facility’s ability to code accurately.

 

How To Avoid Careless Coding: Proper Documentation

“Careless coding jeopardizes reimbursement, and can also lead to fraud and abuse issues. One of the most common mistakes results from poor OP report documentation. And, another involves miscoding procedures due to misunderstanding of the correct coding initiatives edits.”

“Avoid The Four Most Common & Costly Coding Mistakes” Ambulatory Surgery Compliance & Reimbursement Insider. May 2007

Careless coding is not always the direct result of the coders’ mistakes, but rather an error in the physician’s documentation. Basically, physicians and coders speak two different languages – coders speak code-book language and physicians speak clinical language. One would assume that code-book language would rightly align with clinical language; however, that is not the case in the healthcare industry. With such a vast language barrier, how can we expect coders to make accurate decisions of assigning codes when the physician documentation does not match the code-book language they’re required to speak for accurate, compliant documents sent to their third-party payers?

Point-of-Service Documentation: Do you know the value?

“IPA’s should use point-of-service methods to increase quality and ensure the collection of quality data, by central distribution of prompts containing quality codes. Prompts and reminders are important tools to assist physicians in addressing care that may be overlooked or missed.”

“Medicare Quality Codes & Their Impact on Physicians” ICLOPS, LLC. December 2005

Independent Practice Associations (IPA’s), along with other types of healthcare organizations should use point-of-service methods to capture quality data. Capturing quality codes is vastly important. How will physicians know what and how to capture if they don’t have the knowledge and the tools to do so? ComplyMD’s point-of-service documentation solution allows physicians to properly document their procedures and diagnoses, in a code-ready format.

The software doesn’t necessarily ‘prompt’ physicians; however, it provides them with an ‘other procedures/diagnoses to consider’ suggestion box.