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.

Pay for Performance (P4P): Rich Data Creation

One of the quality initiatives set forth by Medicare is their Pay for Performance (also known as P4P) initiative. We have all heard about P4P. “The foundation of effective pay-for-performance initiatives is collaboration with providers and other stakeholders, to ensure that valid quality measures are used, that providers aren’t being pulled in conflicting directions, and that providers have support for achieving actual improvement.”

This is a great piece from a position paper on P4P: “The primary focus of the quality movement in health care should not be on “pay for” or “performance” based on limited measures, but rather on the patient. The American College of Physicians hopes to move the pay-for-performance debate forward with a patient-centered focus—one that puts the needs and interests of the patient first—as these programs evolve.”

I love that point that the American College of Physicians makes…basically, if we can make P4P about the patient and less about “payment” or “performance” then a lot of the fuss over P4P would be put to rest. With ComplyMD, physicians are in the business of rich data creation.

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.