importance of clinical documentation

Sometimes, inadequacy equates to no history and physical or progress notes. Group, 318 F.3d 1199, 1214 (10th Cir. Tex)) (relying on a survey report from the American College of Obstetrics and Gynecology to not renew physician’s privileges). Pitfall: Once payers get involved, physicians could find themselves facing possible fraud and abuse charges – all based on a simple mistake or oversight that snowballed out of control. Reason 4: The False Claims Act [xv] 31 U.S.C. Reason 2: Physician Licensing Medical staff bylaws, hospital bylaws and Joint Commission standards set parameters that promote and ensure quality patient care. “Clinical documentation improvement and billing specialists help ensure hospitals, physician practices, and patients are correctly billed for … The Importance of Clinical Documentation Improvement for Australian Hospitals Implementation of an effective CDI program by competent, trained clinicians can be a powerful tool whose impact is far reaching by its very nature. 2018 Aug;122(8 ... nine post-EHR and two examined both periods. 1982); Lanier v. Sallas, 777 F.2d 321, 323 (5th Cir. Importance of Clinical documentation for accurate ICD-10 coding ICD-10 is not the coding but it’s improved Patient care which is documented Descriptive documentation to support accurate coding is the base of reimbursement from the insurances If physicians don't document … Clinical Documentation: Why is it so Important. Furthermore, a hospital may request a survey that can be used both by a hospital for an internal review and a court.[vi]. Since 2009, two important laws, Fraud Enforcement and Recovery Act of 2009 (“FERA”)[viii] and the Affordable Care Act of 2010 (“ACA”)[ix] expanded whistleblowers’ protections and their ability to bring FCA suits. [v] HealthGrades, available at http://www.healthgrades.com/directory_search/physician/profiles/dr-md-reports/dr-jeffrey-heitkamp-md-2373f5dd/sanctions. Clinical Documentation Improvement in healthcare is important not only because proper documentation is a major component of the hospital’s reimbursement, but also because quality documentation leads to great relationships with other providers within and outside of a health system. Documentation helps to inform and support providers by supplying information to highlight trends, providing insight into disease processes, and uniting physician teams and payers through the flow of data. With FERA amending the FCA, a new basis for liability emerged – knowing retention of an overpayment, regardless of the cause of overpayment. The physician's three surgeries on a patient contributed to the patient's final condition of disability. Is your clinical documentation improvement (CDI) program identifying your outliers? [xiv] Target areas for auditors include: DRG assignment, medical necessity, contractor approved issues, and procedures unrelated to the primary diagnosis. [xiv] CMS, Statement of Work for the Recovery Audit Contractor Program, https://www.cms.gov/RAC/downloads/Final%20RAC%20SOW.pdf (last visited Mar. Bottom Line: Documentation is the physician’s best weapon in his arsenal to maximize both patient care and payer reimbursement. Importance of Documentation and Best Practices in Case Notation. [v], Reason 3: Hospital/Medical Staff Bylaws and Joint Commission Standards UM Comprehensive AIDS Program. Objectives: 1.To demonstrate how the case note is used to provide program accountability 2.To demonstrate how the case note is used to indicate client progress 3.To reinforce the importance of timely, concise, accurate, standardized case notes as a “best practice” in … Clinical records provide uniformity and continuity across visits, hospitals, physicians, and … [ii] Ronald W. Scott, Legal Aspects of Documenting Patient Care, p. 163 (2nd ed. §§1396a(a)(42)(B) and 1395ddd(h). Action Taken: The physician has entered into an Agreed Order with the board for a period of two years subject to the following terms and conditions: The physician's practice shall be monitored by a board designated physician monitor who shall review selected patient medical and billing records. §§ 3730(b)(2)-(4) (1986). Everything hospital executives need to know about the importance of clinical documentation improvement is summed up in one single fact: CDI fuels correct … Elizabeth [2006] states, “the usefulness of abstracted data for quality and safety purposes relies on good documentation in the medical record”. Documentation provides an electronic record (and usually also a hard copy). [iv] In turn, this negatively impacts a physician’s HealthGrades score. The anchor on a cruise ship can hold … The quality of clinical documentation assists in optimising the patient’s care. Accurate and timely clinical documentation by physicians has always been the cornerstone of quality patient care and reimbursement. Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. The success of CDI programs relies on a cooperative effort between physicians, health information management, coders, and clinical documentation specialists. Find Out Which New Therapeutic Service Codes Made the Latest CCI Edit List. Sonya O. Boyne, LMHC. In addition to fines and penalties physicians and hospitals may be required to pay if claims were submitted without adequate documentation, medical errors were made, False Claims Act violations, or a licensing board or Joint Commission imposes a fine, there are other areas that are impacted. 2. A well-documented record can help alleviate liability concerns in the event of a claim. Coders, how do you ask for documentation clarification? Reduces risk management exposure. “According to Section 458.331(1)(m), Florida Statutes, a physician may be disciplined for "failing to keep written medical records justifying the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered, and reports of consultations and hospitalizations." Proper and accurate data sharing are key factors in providing effective patient care. Up to 70% of nurses surveyed stated they were unable to find an indication in the medical record for a treatment they were administering to the patient. [xi] 31 U.S.C. First, the documentation is inadequate and untimely. [xi], Reason 5: Public Notice of State Medical Board Disciplinary Actions A Clinical Documentation Improvement (CDI) program can help hospitals and other providers achieve this. [xii] Texas Medical Board, www.tmb.state.tx.us (Feb. 17, 2010). The physician shall successfully complete eight hours each of continuing medical education in medical recordkeeping, risk management, and lumbar surgery complications and outcomes within two years. Source: Thinkstock Healthcare professionals rely on the accuracy of correct patient information to create and evaluate treatment plans and monitor patient healthcare over time. Providers should ensure that their documentation accurately and meticulously reflects a full picture of the encounter. Are Primary Care Coding Questions Slowing You Down? You Can Only Bill What Has Been Documented. Medical record documentation is a cornerstone to achieving compliance and optimal patient care. Poor clinical documentation is undermining patient care, hospital sustainability and healthcare data integrity The care of all Australians is significantly impacted by poor clinical documentation. During the course of an audit, Recovery Audit Contractors (RACs) are required to relay suspected fraud to the government. (2000). BACKGROUND: Radiology reporting is a clinically oriented form of documentation that reflects critical information for patients about their health care … Surgeons will need to respond quic… Example: “Bacon, Robert J., Jr., MD, Lic. [i][i] James v. Brown, 637 SW2d 914, 918 (Tex. Physician licensure is administered through individual state boards that have the duty of oversight and healthcare consumer protection. To find out more about the specific documentation standards where you practice, contact your state board of nursing. #F0861, Houston, TX – On February 5, 2010, the Board and Dr. Bacon entered into an agreed order requiring Dr. Bacon to pay an administrative penalty…within 90 days. 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 … [x] The caveat is that the information cannot be publically available information. [i] “These guidelines can take the form of federal or state statutory or regulatory requirements, professional association and accreditation standards, and health care organization internal policies, protocols and procedures.”[ii] Failure to conform to an established protocol, may, standing alone, constitute enough evidence that the healthcare provider breached the standard of care. Get Ready Home Health: 8% Behavior-Based Rate Cut Under PDGM Is a Blow, Dig a Little Deeper Into the 2020 ICD-10-CM Revisions (Part 2), Dig a Little Deeper Into the 2020 ICD-10-CM Revisions (Part 1), Leverage Vital Q/A for Optimal Colorectal Cancer Screening Reporting, 3 Complex Neurosurgery Coding Scenarios Made Simple, How to Solve 3 Otolaryngology Coding Scenarios. First, coders cannot rely upon items absent from the record. 3731(c), 3732(a)(1), and 3729(a)(2), (a)(1)(B). It is important to understand what good clinical documentation is and who is responsible for it as well as what these roles potentially offer our health system. [xiii] Centers for Medicare and Medicaid, Hospital-Acquired Conditions, available at https://www.cms.gov/hospitalacqcond/06_hospital-acquired_conditions.asp; Deficit Reduction Act of 2005, §5001(c). [vii] The financial penalties are significant and enable the government to be awarded treble damages plus civil penalties ($5,000-$11,500 per claim). Correct documentation is not only important for hospital reimbursement, but also for ensuring that patients’ bills are accurate as well. 2003); Ex. The Board’s action was based on Dr. Bacon’s failure to meet the standard of care and maintain adequate medical records.”. rel Burns v. A.D. Roe Co., 186 F.3d 717, 722 (6th Cir. [vi] American Academy of Orthopaedic Surgeons, Code of Ethics and Professionalism for Orthopaedic Surgeons – General Principles of Care, §VII(B)(D) available at www.aaos.org; Benson & Benson OB/GYN Center v. St. Josephs Regional Health Center, (2007 WL7120757, 1 (S.D. Furthermore, since it is ultimately the physician’s responsibility to establish the cause and effect relationship of the disease process, a fully documented record provides him with the tools he needs to make that determination. This will, in turn, maximize reimbursement and revenue. By not documenting, opportunities to capture CCs and MCCs are lost. 1-866-670-0767 1991) (holding that information is not considered publically disclosed if “the communication does not release the information into the public domain such that is accessible to the general population.”). Clinical documentation improvement (CDI) roles are being increasingly created in Australian hospitals. Importance of Clinical documentation for accurate ICD-10 coding - Medical Coding 1. Period. 67, 12 Stat. © 2020 The Coding Institute LLC. 1999); U.S. ex rel Hagood v. Sonoma County Water Agency, 929 F.2d 1416, 1419 (9th Cir. The record allows the entire healthcare delivery team to provide quality patient care. Professional documentation includes Any and all forms of documentation by a clinician recorded in a professional capacity in relation to the provision of patient care. [vii] Act of March 2, 1863, ch. No matter what the Centers for Medicare & Medicaid decide to do with the ICD-10 implementation deadline, clinical documentation improvement (CDI) may become a survival tactic for hospitals.CDI is a process typically used in hospitals that employs specialists who review clinical documents and provide feedback to physicians, says Mark Morsch, vice president of technology at … Good documentation is an important part of improving both patient care and nursing practice. Medical Boards publically release the findings of disciplinary hearings and can order an administrative penalty for failure to meet the standard of care for not maintaining adequate medical records.[xii]. Documentation provides a valuable account of a patient’s concerns, as described to the physician, and the physician’s assessment of, and findings about, the patient’s condition and resulting treatment plans. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services. The capturing of all diagnoses that are relevant to the treatment, socioeconomic, and/or psychosocial circumstances are important to accurately capture the patient’s clinical picture and potential health hazards, therefore providers should be educated on the impact of these additional diagnoses. The legal standard of care or the required practice standards in a given situation, form the basis of a legal claim, which is often a state negligence or deceptive trade practice claim, or a component of a federal claim such as the Anti-kickback or False Claims statutes. Reason 1: Standard of Care Medical notes are a vital means of communication between all those providing care to the patient and also of relevant communication with patients themselves and their relatives. 1985). Remember: Payers determine eligibility for payment through the documentation submitted to substantiate the claim. Undetected problems in medical records can fester, impacting everything that is later built upon that faulty information, including billing for services that may not have been provided. Reason 6: Adverse Financial Consequences 20, 2011). Providers are mandated by law and regulatory bodies to capture some form of record about an encounter with each patient. Bottom Line: Regardless of what procedures the physician performs – and how mandatory or integral it is that the procedure be performed in line with the rest of the documented services – if a particular procedure is not documented, it does not get reimbursed. Devkaran, S, O’Farrell, P (2014) The impact of hospital accreditation on clinical documentation compliance: a life cycle explanation using interrupted time series analysis. These notes provide a baseline from which any provider can build, review, and follow up on treatment plans. Clinical records provide uniformity and continuity across visits, hospitals, physicians, and payer providers. Many of us already know this familiar phrase, “If it has not been noted in the record, then it never happened.” A procedure must be indicated and substantiated on the chart and included in the Electronic Medical Record (EMR) for the payers (and auditors) to accept a claim for that service. [iii] See Delaware Board of Medical Licensure and Discipline (http://dpr.delaware.gov/boards/medicalpractice/index.shtml); The Medical Board of California (www.medbd.ca.gov/); Texas Medical Board (www.tmb.state.tx.us); Pennsylvania Department of State, State Health Licensing Boards (www.licensepa.state.pa.us/); and Florida Board of Medicine (www.doh.state.fl.us/mqa/medical/me_faq.html). [viii] 31 U.S.C. The Board’s oversight duties do not end with the initial administration of a license, but rather continues as long as a physician or other health care professional (Physician Assistant or Nurse Practitioner) continue to practice. The top audit trigger is improper or inaccurate billing. Overall, it is imperative for hospitals and physicians to collaborate in relation to appropriate and timely clinical documentation. [ix] 42 U.S.C. Just as patients rely on numerous providers and healthcare professionals to maintain a good state of health, passengers on a cruise ship rely on numerous crew members to ensure they have smooth sailing and stay on course. In healthcare, over the past 25-30 years we’ve seen the use, need, and importance of clinical documentation and coding greatly increase. clinical documentation will be scrutinised at some point. Increasingly, medical records are pivotal to medicolegal cases and litigation. Given the complexity of health care and the fluidity of clinical teams, healthcare records are one of the most important information sources available to clinicians. Because RAC auditors can also file a qui tam suit, there is an additional incentive. The benefits surrounding its success internationally include improved quality and patient safety outcomes and increased reimbursement. Clear Up Confusion with Routine Checks for Quality Control. Moje et al. This item appears in the following Collection (s) Informatics Graduate Theses and PhD Dissertations Informatics School Theses and Dissertations Aside from an adverse patient outcome, there are numerous ways that healthcare providers are subject to adverse legal, financial, and publicity in relation to clinical documentation. And the importance of complete, accurate, concise, timed and dated documentation cannot be overstated. Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. Therefore, it is imperative that physicians audit their medical records frequently to identify any potential issues before they become a problem. Therefore, as evidenced in this study, Clinical Documentation Improvement Programs are an important initiative to implement at any healthcare institution. CDI programs may comprise coding and/or nursing specialists assisting physicians on documentation in order to allow for timely and accurate coding. 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. Clinical documentation implementation (CDI) programs can be beneficial in this transition. Second, because of the revenue a particular physician is generating, his/her disregard for completeness and/or timeliness of clinical documentation is “overlooked.” By not addressing these issues, both the hospitals and physicians are taking significant risks. All Rights Reserved. 696; 31 U.S.C. Physician Expert, Clinical Documentation Key to MIPS Success An industry expert advised practices to develop physician-led MACRA implementation teams that emphasize clinical documentation improvements for MIPS success. Documentation queries may be helpful in clarifying diagnosis codes. Section 456.057(14), Florida Statutes.”. Failure to keep adequate medical records (12/12/08), Issued To: Dr. Jeffrey Wade Heitkamp; License # F4064, State: Texas, Nature of Complaint: The physician failed to adequately document a complete examination and history that would justify surgical intervention in a patient with back and leg pain or discussions of alternatives to surgery. §§ 3729–3733, also called the "Lincoln Law. The impact of electronic health record systems on clinical documentation times: A systematic review Health Policy. In order to avoid having to pay back previously reimbursed claims plus interest or going through a lengthy appeals process, better documentation decreases RAC findings. Complete and accurate documentation validates the care provided shares key data with subsequent caregivers and allows coders to code accurately to ensure the hospital is fairly paid. 3730(4)(A); U.S. Ex. Proper documentation promotes safe patient care, good communication among staff members, and the advancement of the nursing profession. The importance of clinical documentation improvement for Australian hospitals Clinical documentation improvement (CDI) is a recent initiative gaining increased momentum in Australia. [iv] Pinellas County Medical Association, available at http://www.pinellascma.org/medrecords.html. In relation to clinical documentation, hospital executives, employees and fellow medical staff members often express two scenarios. [iii] A physician’s license may be revoked or suspended for failing to keep proper medical records. Documentation is an essential component of effective communication. Documentation communicates the quality of clinical care that providers are delivering to patients and serves as a means to facilitate the continuum of care, from EM to HM and beyond. Second, if a condition is not documented as present on the first admission and is included in the Hospital-Acquired Conditions list set forth by CMS, if a patient is readmitted for an item on the list, then the healthcare provider does not get reimbursed.[xiii]. All Rights Reserved. The importance of good documentation practice needs to be emphasized to investigator sites to ensure that the study results are built on the foundation of credible and valid data. The above factors are especially important with clinical documentation improvement (CDI). Documentation mitigates risks and reduces the chance of malpractice. BMJ Open [online] 4(8): e005240 – e005240 . Does your documentation capture the level of ICD-10 coding specificity required to achieve optimal reimbursement? Reason 7: RAC and Other Audits To learn more about the value of documentation—and to get the inside scoop on CDI methods and strategies—pick up your copy of TCI’s must-have Clinical Documentation Sourcebook.

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