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.

The Results Are In….One Office Coder Tells Her Story on the Benefits of ComplyMD

Physicians who currently use ComplyMD, have seen great results in their documentation. They are more aware of the benefits of capturing accurate, real-time documentation: benefits to the patient, benefits to themselves, benefits to the hospital/ASC, and benefits to their office staff. Here, I’d like to focus on some great feedback we received from one practice’s office coder.

And I quote…

-Chart accuracy has improved by 75%.

-Specifically, our physicians are now documenting their (1) lesion removals and (2) incision and drainage of abscesses more accurately, resulting in more accurate coding and reimbursement for our office.

-The free-text availability in ComplyMD has proven helpful in coding procedures and diagnoses. Our physicians are able to better communicate to us exactly what they did, along with the exact condition of the patient.

-Our billing department has become a more efficient, productive place with the utilization of ComplyMD.

-Our work load has decreased by about 40%.

-Increased ComplyMD usage has decreased the frequency of phone calls to the hospitals’ HIM departments by 80%.

-ComplyMD promotes a more efficient, more accurate method of documentation and coding among healthcare professionals.

Real people. Real results. Why not document with ComplyMD?

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?

Healthcare Technology Meets Documentation: How Your Facility Can Benefit

“The industry in general is not being proactive in implementing measures that will ensure accurate charging and reduce the amount of denied claims. Technology has the greatest potential for improvement for any provider.”

“Improving Cash Flow with Better Charge Capture & Denial Management” MedAssets & HFMA. October 2005

How do we, as an industry, ensure accurate charging and help reduce the amount of denied claims? First, let’s talk about how we are able to ensure accurate charging. What do facilities charge for? They charge for services rendered and supplies used to render those services. So we must accurately capture services, right? Well, how will we accurately capture services? Through proper documentation. Accurate charges are ensured through accurate documentation. Now, how can we capture accurate documentation? Obviously the way we’ve been doing business (after-the-fact dictation, 3×5 pocketed index cards, among other archaic methods) does not cut it. So, that’s where technology comes into the picture.

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.