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Recognizing the Value of Clinical Documentation Improvement

May 20, 2014
by Rajiv Leventhal
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A consultant explains why clinical documentation is as important as ever in healthcare

In patient care organizations, proper and accurate clinical documentation has always been important, but in today’s shifting healthcare landscape, it has become even more of a strategic imperative than perhaps ever before. Documentation is critical for patient care, not only because it validates the care that was provided, but also because it shares key data with subsequent caregivers and optimizes claims processing. As such, clinical documentation improvement (CDI) programs are important to any facility that recognizes the necessity of complete and accurate patient documentation.

But even as successful CDI programs become more prevalent in hospitals and health systems across the country, many physicians still don’t really understand the importance behind it, says Wendy Vincent, national practice director, strategic advisory group at Beacon Partners, a Weymouth, Mass.-based consulting firm. Engaging physicians to improve their clinical documentation is critical to the success of the entire healthcare organization, yet getting physician buy-in for this strategy remains difficult, notes Vincent, who sees this problem occurring for many of her clients.

At the core of the problem is that physicians are extremely busy, Vincent says, and because of that, they’re not connecting the dots on clinical documentation. As a result, Vincent advises that the best way to deal with their demanding schedules is to engage them in a positive way, train them, and give them time to see the relevance in improving their documenting. “A good CDI program has key executives engaged and transparent, with physician leadership all the way up to the CMO,” she says. “The organization needs to embrace it.”

But the issue extends beyond just a lack of time, Vincent continues. “For the most part, physicians are very smart, but when they go to medical school, they don’t take a course on how to document well—they are concerned with providing good care,” she says. “And that is something that we understand, so we go in and begin to look at large physician practices and run reports to see where the outliers are and what physicians need the most. Once we take a look where the low-hanging fruit is, we begin to work with those physicians and take them through training to help them understand what they’re doing today and where there are areas for opportunity to do a better job documenting. This will avoid risk, and improve and maintain their high quality of care, as well as optimize their reimbursement,” she says.

The Importance of Better Documenting

Physicians might not be quite in tune as to the impact poor documentation can have on the bottom line, Vincent says, but in reality, there are three real reasons how this can negatively affect an organization. If a facility has an acute care patient who has pneumonia, for example, and that patient is going through different levels of care and different stages, there needs to be exact documentation, Vincent explains. “I have a nursing background, and I’m a firm believer in the saying, ‘If it hasn’t been documented, it hasn’t been done.’ If it’s not documented appropriately, the organization is at risk of not following through what needed to be done for a particular predicament,” Vincent says.

Secondly, documenting always avoids any issues, she continues. “It shows that good quality care has been done, and provides valuable information among an interdisciplinary team of physicians, nurses, physical therapists, respiratory therapists, etc. Good documentation clearly shows the care that has been done, the diagnosis, and what is left to do,” Vincent says.

Additionally, if there is a particular diagnosis code and a physician documents too quickly, it could be reimbursement for a certain value when in reality, the care that was provided and performed is a different level of care than what was documented, explains Vincent. “You look at the levels of reimbursement based on documenting appropriately, so you could be talking about fairly significant dollars to an organization. “And you’re not talking about just soft dollars, but instead hard reimbursement dollars that the organization can obtain.”

The ICD-10 Effect

Documentation practices have been considered by many to be the top driver for ICD-10 success, given that clinical documentation must meet the level of coding specificity and granularity required to: achieve optimal reimbursement; meet all regulatory and reporting requirements; and accurately reflect the level of care provided. Vincent says that when she talks to clients across the country, one of the key things she needs them to takeaway is that a good CDI program and good documentation is a fundamental critical step to achieving a successful ICD-10 implementation.

“Whether it’s right or wrong, the delays to ICD-10 have impacted the industry once again,” Vincent says. “When federal regulations are delayed or postponed, many of our clients stop the work and push it off. We say that if you’re going to stop and delay your ICD-10 work, let’s at least go ahead and talk about how you can fix your documentation and your coding, and optimizing that, because that’s one more step that will bring them closer and aligned to being in good shape to when you do have to cross over,” she says.

Certainly, some might see the delay of the ICD-10 compliance date as a "silver lining,” in that providers can take advantage of the delay to improve their clinical documentation skills. But Vincent says that for her clients, the delay is perceived as both positive and negative. “It’s seen as a positive because it’s another thing they don’t have to deal with, but also a negative to some because they have already spent the dollars, they’re ready, and they’re concerned about the potential of not moving ahead at all. But I don’t think that will be the case—I believe we will move forward,” she says.