Objectives
Documentation Matters
Documentation Matters
Background
Background
Hospital Reimbursement
1965 - Medicare reimbursed hospitals based on
actual charges for treatment provided
Background
Hospital Reimbursement
2007 - CMS introduced Medicare Severity Diagnosis
Related Groups (MS-DRGs)
Background
Hospital Reimbursement
CMS anticipated facilities would focus on
documentation improvement
Background
Documentation Matters
Impact of clinical
documentation
Patient
Physician
Facility
Quality of care
provided
Continuity of care
Non-payment by
Insurance for
illegible condition
or treatment
Demonstrates
accountability
Performance
Management
Reduced or denied
payment
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Documentation Matters
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Documentation Matters
Principles of Documentation
Documentation Matters
Principles of Documentation
Documentation Matters
Principles of Documentation
Change in diagnosis
Response to treatment
Change in treatment
Patient non-compliance
Documentation Matters
In a nut-shell
Complete
Legible
Accurate
Patient
Centered
Clinical
Documentation
in the Medical
Record should
be
Clear
Timely
Concise
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Documentation Matters
Communication
tool between
providers
Ability of
physicians and
other health care
professionals to
evaluate & plan
the patients
care
Accurately and
timely claims
review &
reimbursement
Used for
research and
education
Utilization
Review &
Quality of care
evaluation
Collection of
data and
Resource
Management
Documentation Matters
Progress Notes
Nursing Notes
Medication Record
Flow Charts
Orders
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Documentation Improvement
Key Implementation Factors
Organizational Support
Leadership Support
Resources
Professional Development
Available Medical Record and Coding Staff
Support Staff
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Documentation Improvement
Identify Resources
Personnel
Systems availability
Set Goals
Buy-in
Measure Performance
Market and promote program
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Documentation Improvement
Assessment
Inpatient
Outpatient
Percentage of Coding errors
CC/MCC capture rate
Diagnosis/Procedure omission
Accuracy of DRG assignment
Percentage of Coding Errors due to documentation
Documentation Improvement
Goals
Improve documentation to ensure good quality of care
Optimal reimbursement
Correct Coding and DRG Assignment
Improve patient outcomes
Patient satisfaction
Continuous coding education/training
Physician education/training
Capturing severity of illness
Complications and co-morbidities
Documentation Improvement
Buy-in
Entire MTF needs to commit to the documentation
improvement program
Present benefits
Metrics variance
Include example of results
Documentation Improvement
Team Composition
Model #1 HIM
Nurses
RHITs
Clinical Coding Specialists
Documentation Improvement
Providers
Missing test results
Physician orders
Documentation Improvement
Concurrent queries
Decrease Backlog
Minimize retrospective queries
Performance Measures
Reporting Metrics
DRG Focus Areas
Sepsis
Chest Pain
Symptom code as Principal Diagnosis
Acute Renal Failure versus Dehydration
Congestive Heart Failure
Documentation Improvement
Benefits/Outcomes
Physician Education
One-on-One or Group
Promote the program
Ask for inclusion in medical staff morning or afternoon
meetings
Develop documentation tips by department
Create newsletter
Physician Documentation Report Card
Provide incentives for best results
Example: Lunch
Monitoring Performance
Measure successes
Identify any barriers
Measure the productivity and quality of the CDI Team
members
Identify training opportunities
Reward Staff
Summary
Why is clinical Documentation Important?
Summary
A successful clinical documentation program leads to
Summary
Revenue is Revenue
But
Clinical Documentation is Important
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Questions?
Resources
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Background Slides
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