Implementation of Clinical Documentation Improvement Programs in the hospital setting has grown exponentially over the last few years as a key financial strategy to address and meet the tough economic challenges faced in today’s current healthcare business climate. Hospitals have elected to implement these programs through either a “home grown” process or contracted with consulting companies for guidance, expertise and development of a formal clinical documentation improvement. Regardless of implementation approach taken, the full potential benefits of most clinical documentation improvement program initiatives are generally not being recognized and taken advantage as part of this key financial strategy.
Established goals of the CDIP program
The fundamental premise for the implementation of a clinical documentation improvement program is increased reimbursement through achieved improvement in case mix from expanded and improved specificity of clinical documentation that affords the hospital the ability to capture and code for complications/comorbidities and major complications/comorbidities as well as higher severity principal diagnoses. Documentation of these diagnoses allows for the assignment and billing of a higher weighted MS-DRG translating into higher reimbursement for the hospital. This strict focus upon clinical documentation improvement for purposes of enhancement of revenue for the hospital poses significant limitations and numerous potential compliance risks for the hospital, opening the hospital to increased financial scrutiny and possible financial recoupments by the Recovery Audit Contractor, Medicare Administrative Contractor, CERT Contractor and soon to be Medicaid associated Recovery Audit Contractors as examples. There will be more discussion on this note later in the article.
Expanded goals of the CDIP program
The expenses associated with the development and implementation of any clinical documentation improvement program consume precious hospital capital, a commodity in short supply with current revenue shortfalls experienced by many in the hospital community. As such, the initial and evolving true to form goals of any clinical documentation improvement program must capitalize upon the opportunity to take advantage of and facilitate a complete, accurate, specific and detailed medical record documentation in support of the wide array of uses of the data emanating from the record. A medical record that adequately and fully reflects patient’s true severity of illness, risk of morbidity and mortality, risk of thirty day readmission, promotes continuity of care post discharge from the hospital, meets reasonable and medical necessary standards with supporting documentation from the interdisciplanry care team and strong demonstration of adherence to best practice standards and efficiencies of medical care, will provide for a substantially greater degree of hospital return on its investment.
Goals of a CDIP Program: How expansive should they be?
Establishing valid and reliable goals of any clinical documentation improvement program must incorporate the values and principles of the organization as a whole in addition to those of the practicing physicians, the major stakeholders in the program. It goes without saying that absent full physician buy-in and participation in efforts at improving clinical documentation will result in the program failing to achieve maximum potential of affecting positive change in behavior modification of overall physician documentation patterns. Behavior modification of deficient physician practice patterns of clinical documentation is the hallmark of achieving long-term success of any clinical documentation improvement program.
Serious consideration in the establishment of the following reasonable, attainable goals of should be undertaken as part of the planning, development, and implementation process of any new clinical documentation improvement program. If your facility has an operationally established clinical documentation improvement program, now is the time to reassess the achievements and successes of the program and interject some of these stated goals as part of a continuous quality improvement initiative. These specific goals include:
The goal of reducing and mitigating financial exposure begins with recognizing clinical documentation improvement for its ability to accurately capture and reflect the patient’s true severity of illness, physician’s clinical judgment, medical decision-making in support of medical necessity for inpatient admission, clinical confirmation and rationale for physician conclusory statements of diagnoses, and enhanced interdisciplanry care team documentation of assessments, interventions and outcomes that serve to represent the patient’s clinical picture and responses to treatment. Clear, concise, and complete clinical documentation is paramount to the establishment of medical necessity for inpatient admission, beginning with phsyciian and nursing documentation in the Emergency Room, extending to the physician’s dictated History and Physical and continuing with the consultant reports, daily progress notes, ancillary care discipline notes, and ending with the discharge summary. A sound clinical documentation improvement program will recognize and capitalize upon the opportunity to promote the concept of medical necessity through incorporation into the goals, objectives, processes and principles of the design and implementation of the program. Each healthcare discipline must understand and appreciate and understand the synergies of clinical documentation in support of medical necessity and the financial health of the organization.
Seizing the Opportunity: Carpe Diem
Seizing the ability to realize the fullest potential of a clinical documentation improvement program is predicated upon expanding the focus of the program beyond strict enhancement of reimbursement, recognizing that the capture and reporting of CCs and Major CCs represents only one small part of the equation. The ultimate goal of any clinical documentation improvement program is affecting positive change in behavior modification of physician patterns of clinical documentation beginning with the physicians in the Emergency Room and extending throughout the record in promotion of a complete, consistent and accurate documented record. Other ancillary care staff can be brought into the educational fold of clinical documentation improvement as the program progresses with the primary goal of Res Ipsa Loquitor- the thing (record) speaks for itself. There is no time like the present to transform the clinical documentation improvement program process from a narrow to a holistic approach perspective. The continued health of the organization in the near, mid and long term is dependent upon operationally effective clinical documentation improvement programs that addresses the immediate financial challenges imposed by the MS-DRG system while preparing the organization for the increased degree of completeness and accuracy of clinical documentation necessary under proposed healthcare delivery and reimbursement models
YPRO Corp. provides clinical documentation improvement program services for hospitals and physicians, focusing upon the promotion of synergies of complete, accurate, and effective clinical documentation to the business of medicine from both a hospital and physician perspective.
Established goals of the CDIP program
The fundamental premise for the implementation of a clinical documentation improvement program is increased reimbursement through achieved improvement in case mix from expanded and improved specificity of clinical documentation that affords the hospital the ability to capture and code for complications/comorbidities and major complications/comorbidities as well as higher severity principal diagnoses. Documentation of these diagnoses allows for the assignment and billing of a higher weighted MS-DRG translating into higher reimbursement for the hospital. This strict focus upon clinical documentation improvement for purposes of enhancement of revenue for the hospital poses significant limitations and numerous potential compliance risks for the hospital, opening the hospital to increased financial scrutiny and possible financial recoupments by the Recovery Audit Contractor, Medicare Administrative Contractor, CERT Contractor and soon to be Medicaid associated Recovery Audit Contractors as examples. There will be more discussion on this note later in the article.
Expanded goals of the CDIP program
The expenses associated with the development and implementation of any clinical documentation improvement program consume precious hospital capital, a commodity in short supply with current revenue shortfalls experienced by many in the hospital community. As such, the initial and evolving true to form goals of any clinical documentation improvement program must capitalize upon the opportunity to take advantage of and facilitate a complete, accurate, specific and detailed medical record documentation in support of the wide array of uses of the data emanating from the record. A medical record that adequately and fully reflects patient’s true severity of illness, risk of morbidity and mortality, risk of thirty day readmission, promotes continuity of care post discharge from the hospital, meets reasonable and medical necessary standards with supporting documentation from the interdisciplanry care team and strong demonstration of adherence to best practice standards and efficiencies of medical care, will provide for a substantially greater degree of hospital return on its investment.
Goals of a CDIP Program: How expansive should they be?
Establishing valid and reliable goals of any clinical documentation improvement program must incorporate the values and principles of the organization as a whole in addition to those of the practicing physicians, the major stakeholders in the program. It goes without saying that absent full physician buy-in and participation in efforts at improving clinical documentation will result in the program failing to achieve maximum potential of affecting positive change in behavior modification of overall physician documentation patterns. Behavior modification of deficient physician practice patterns of clinical documentation is the hallmark of achieving long-term success of any clinical documentation improvement program.
Serious consideration in the establishment of the following reasonable, attainable goals of should be undertaken as part of the planning, development, and implementation process of any new clinical documentation improvement program. If your facility has an operationally established clinical documentation improvement program, now is the time to reassess the achievements and successes of the program and interject some of these stated goals as part of a continuous quality improvement initiative. These specific goals include:
- Holistic approach to clinical documentation. Promote holistic approach to clinical documentation improvement through promotion of the synergies of clinical documentation between the hospital and the physician’s business of the practice of medicine through his/her Evaluation and Management assignment. There exist tremendous realized clinical synergies of documentation between accurate ICD-9 code/ MS-DRG assignment and E & M assignment. Accurate clinical documentation in support of amount of and medical necessity for physician work performed is a basic tenet of E & M assignment for physicians. Considering the present state and trend of hospital ownership of physician practices and employment of hospitalists/intensivists, it is the vested interest of the hospital to capitalize upon the opportunity to capture complete, accurate and effective clinical documentation from a shared interest business model perspective.
- Completeness and consistency. Promote completeness and consistency in clinical documentation throughout the record, capturing documentation of all relevant clinical diagnoses within the record, regardless of whether the diagnosis is a “CC” or “MCC” that reflects potential reimbursement. A major pitfall of many CDI programs is the focus upon capturing only the diagnoses that impact reimbursement, thereby leaving unrealized opportunities for improved accuracy in the reporting of severity of illness and risk of morbidity/mortality measures and other elements of data instrumental to the measure and reporting of value based performance, quality of care achievement, hospital and physician cost effectiveness/efficiency measures, and healthcare provider accountability and financial risk reduction measures. Each of these performance based measures plays an integral role and foundation for renewed efforts at healthcare delivery and payment transformation from the current unsustainable fee-for-service payment model to value, performance based models such as accountable care organizations, shared savings/gain sharing, medical homes, bundled payments, and episode group payments. Medicare recently announced fourth year results from the Physician Group Practice Demonstration project designed to improve preventive and chronic care delivery processes and generate shareable savings for the Medicare program. Five physician groups will receive performance payments totaling $31.7 million as part of their share of $38.7 million of savings generated for the Medicare Trust Funds in performance year four. These demonstration project financially based quality of care achievements are testimony to continued emphasis and intent of Medicare to transition away from the traditional “value blind” volume based fee-for-service healthcare delivery model.
- Reduce and mitigate financial exposure of payor scrutiny. Serve to reduce and mitigate financial exposure from increased third party payer scrutiny of provider coding and billing for rendered services. Prominent in the clinical documentation improving community is the notion of these programs helping to “safeguard” revenue for the hospitals in the sense the improved clinical documentation solidifies code and MS-DRG assignment. In actuality, present day efforts at clinical documentation improvement contribute to increased exposure to financial take backs and recoupments through introduction of CCs and/or MCCs that have a tendency to be documented and appear only once in the record. This lack of consistency in clinical documentation of relevant clinical conditions that are being managed throughout the hospital stay plays into the Recovery Audit Contractor’s initiatives to question the clinical significance of these one-time documented diagnoses, remove the diagnoses from the paid claim, and thereby change the assigned MS-DRG to a lesser reimbursing MS-DRG.
The goal of reducing and mitigating financial exposure begins with recognizing clinical documentation improvement for its ability to accurately capture and reflect the patient’s true severity of illness, physician’s clinical judgment, medical decision-making in support of medical necessity for inpatient admission, clinical confirmation and rationale for physician conclusory statements of diagnoses, and enhanced interdisciplanry care team documentation of assessments, interventions and outcomes that serve to represent the patient’s clinical picture and responses to treatment. Clear, concise, and complete clinical documentation is paramount to the establishment of medical necessity for inpatient admission, beginning with phsyciian and nursing documentation in the Emergency Room, extending to the physician’s dictated History and Physical and continuing with the consultant reports, daily progress notes, ancillary care discipline notes, and ending with the discharge summary. A sound clinical documentation improvement program will recognize and capitalize upon the opportunity to promote the concept of medical necessity through incorporation into the goals, objectives, processes and principles of the design and implementation of the program. Each healthcare discipline must understand and appreciate and understand the synergies of clinical documentation in support of medical necessity and the financial health of the organization.
Seizing the Opportunity: Carpe Diem
Seizing the ability to realize the fullest potential of a clinical documentation improvement program is predicated upon expanding the focus of the program beyond strict enhancement of reimbursement, recognizing that the capture and reporting of CCs and Major CCs represents only one small part of the equation. The ultimate goal of any clinical documentation improvement program is affecting positive change in behavior modification of physician patterns of clinical documentation beginning with the physicians in the Emergency Room and extending throughout the record in promotion of a complete, consistent and accurate documented record. Other ancillary care staff can be brought into the educational fold of clinical documentation improvement as the program progresses with the primary goal of Res Ipsa Loquitor- the thing (record) speaks for itself. There is no time like the present to transform the clinical documentation improvement program process from a narrow to a holistic approach perspective. The continued health of the organization in the near, mid and long term is dependent upon operationally effective clinical documentation improvement programs that addresses the immediate financial challenges imposed by the MS-DRG system while preparing the organization for the increased degree of completeness and accuracy of clinical documentation necessary under proposed healthcare delivery and reimbursement models
YPRO Corp. provides clinical documentation improvement program services for hospitals and physicians, focusing upon the promotion of synergies of complete, accurate, and effective clinical documentation to the business of medicine from both a hospital and physician perspective.