", Copyright © 2011-2020 BCE Healthcare Advisors. October 06, 2017 - Clinical documentation improvement (CDI) is the process of enhancing medical data collection to maximize claims reimbursement revenue and improve care quality.. Likewise, comprehensive, accurate documentation is important to all stakeholders in health care, from patients to providers, payers to researchers. §§ 3730(b)(2)-(4) (1986). Sometimes patients will be at one location for their care and the documentation is the anchor that provides the information needed for the healthcare teams to stay on course. Californian Sentenced to Prison for HIPAA Violation, Information Blocking Implementation Roadmap, HIM’s How to Thrive Guide: COVID-19 Challenges Met, Lessons Learned and Advice to Forge Ahead, Information Blocking and HIPAA: Road to Compliance, Accurate Provider Data Governance Essential for Patient Care, Why Hospitals Need to Rethink Privacy and Information Security Models, Working from Home During COVID-19: Challenges and Solutions, AHIMA Webinar Addresses COVID-19 Medical Record Documentation Challenges. The benefits surrounding its success internationally include improved quality and … Medical records are a crucial form of communication. [xv] 31 U.S.C. The significant role CDI plays in healthcare has become apparent with the transition from the inpatient to the outpatient environment and from a financial to a quality focus. 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. timeliness, privacy, and security of The benefits of clinical documentation improvement. The impact seen throughout the different settings will vary. The importance of high-quality clinical documentation across the continuum of healthcare can be recognized in the analogy of a cruise. Complete documentation is that which includes maximum content; reliable documentation is trustworthy and safe.5. [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. Clinical documentation improvement specialists are trained to have a firm grasp the clinical details of high-quality care and to be able to spot gaps in electronic health record charting. #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. [vii] The financial penalties are significant and enable the government to be awarded treble damages plus civil penalties ($5,000-$11,500 per claim). https://www.medicare.gov/coverage/inpatient-hospital-care, https://www.hopkinsmedicine.org/health/conditions-and-diseases/congestive-heart-failure-prevention-treatment-and-research. If the outpatient CDI professional focuses on recognizing high-quality documentation and not just elements needed for HCC capture, they can better validate when all documentation meets the characteristic to be of high-quality, which would then accurately represent the disease burden across all settings. 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. Physician licensure is administered through individual state boards that have the duty of oversight and healthcare consumer protection. Precise documentation is accurate, exact, and strictly defines the patient’s conditions.3 An example of a diagnosis that should be assessed for precision is the diagnosis of congestive heart failure (CHF). However, this should not lead the CDI professional to silo their health record reviews into only clarifying for documentation elements that impact reimbursement, but rather focus on high-quality documentation that accurately tells the patient story. In the outpatient setting the documentation of CHF is enough information for the condition to fall into an HCC. Tammy Combs (Tammy.Combs@ahima.org) is director, HIM practice excellence, CDI/nurse planner, at AHIMA. Because RAC auditors can also file a qui tam suit, there is an additional incentive. Clinical documentation must incorporate the concept of the “Golden Thread”. 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. Initially created in 1863, the False Claims Act (FCA) enables the federal government to combat waste, fraud and abuse against those who are reckless, deliberately ignorant, or knowingly make false representations to the government. 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. [viii] 31 U.S.C. CDI professionals should be aware of the impact of clinical documentation across the continuum of care. Patients flow through numerous care settings within the vast healthcare matrix, including inpatient and outpatient areas. First, the documentation is inadequate and untimely. [iv] In turn, this negatively impacts a physician’s HealthGrades score. patient health information. Your email address will not be published. [iv] Pinellas County Medical Association, available at http://www.pinellascma.org/medrecords.html. 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. A... 3. [v], Reason 3: Hospital/Medical Staff Bylaws and Joint Commission Standards JOURNAL of AHIMA—the official [i][i] James v. Brown, 637 SW2d 914, 918 (Tex. Inpatient care is reserved for a higher intensity of care that is delivered in a hospital setting while outpatient care requires a lower level of intensity and may be delivered either within or outside of a hospital. Congestive Heart Failure: Prevention, Treatment and Research. [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. US Centers for Medicare and Medicaid Services (CMS). Improve Clinical Documentation Quality, Improve Health Care The physician's three surgeries on a patient contributed to the patient's final condition of disability. The different healthcare reforms that have been introduced have only served to highlight how critical it is to ensure the maximum accuracy for all documents at all times. [xiv] Target areas for auditors include: DRG assignment, medical necessity, contractor approved issues, and procedures unrelated to the primary diagnosis. §§ 3729–3733, also called the "Lincoln Law. 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. Section 456.057(14), Florida Statutes.”. Ensuring an accurate problem list Documentation communicates the quality of clinical care that providers... 2. Overall, it is imperative for hospitals and physicians to collaborate in relation to appropriate and timely clinical documentation. Clinical documentation improvement (CDI) is a recent initiative gaining increased momentum in Australia. With this assortment of care settings, it would be detrimental to the patient if a provider only considered the care that was provided in one setting to guide their medical decision-making. A characteristic of high-quality clinical documentation is documentation that is precise. Sometimes, inadequacy equates to no history and physical or progress notes. 20, 2011). 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.”). [xi], Reason 5: Public Notice of State Medical Board Disciplinary Actions In the outpatient setting some payers will classify diseases into hierarchical condition categories (HCCs); these also have weights associated with them, which can be used to calculate a risk adjustment score. DRGs also impact the case mix index (CMI), which is the average of all the DRG relative weights to capture the patient’s disease burden. Within each of the areas there are various care-focused groups. The importance of high-quality clinical documentation across the continuum of healthcare can be recognized in the analogy of a cruise. 3730(4)(A); U.S. Ex. David Newton, a Clinical Documentation Manager, and Michelle Brooks, a Corporate Director of Case Management in Clinical Documentation Improvement (CDI) at Baptist Health Care, discuss the importance of accurate and timely clinical documentation and how they have seen CDI transform hospital and patient outcomes. 67, 12 Stat. This information is needed to recognize the return on investment when developing and managing a CDI program. Undetected problems in medical records can fester, impacting everything that is … Allina Health provided education and support to clinicians, office managers, and office staff, developing widespread understanding of the importance of accurate clinical documentation and the reimbursement impact. Reason 2: Physician Licensing The feedback is designed to fill gaps in documentation such as questions about coding, quality measures and overall care management of a patient. The clinical documentation in the health record must support the presence of all patient condition/diagnoses, along with the provider’s assessment and plan for management of each condition, especially chronic conditions. [xiv] CMS, Statement of Work for the Recovery Audit Contractor Program, https://www.cms.gov/RAC/downloads/Final%20RAC%20SOW.pdf (last visited Mar. Group, 318 F.3d 1199, 1214 (10th Cir. Healthcare professionals rely on the accuracy of correct... Beware the Snowball Effect. With FERA amending the FCA, a new basis for liability emerged – knowing retention of an overpayment, regardless of the cause of overpayment. [vii] Act of March 2, 1863, ch. Improved Outcomes. Keeping proper records improves patients' clinical outcomes once they leave the … [iii] A physician’s license may be revoked or suspended for failing to keep proper medical records. 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