Clinical Documentation Improvement for Revenue Integrity

October 23, 2019


In a hospital’s clinical efforts there are certain key focus areas that can make or break the integrity of revenue collected for services provided. Clinical documentation improvement (CDI) is critical in the revenue cycle flow. When this process accurately reflects the clinical care a patient receives, billing results greatly enhance.

“As healthcare organizations continue to utilize data that is becoming increasingly complex, it is essential that the data is captured and documented properly. Clinical documentation improvement (CDI) helps ensure that the events of the patient encounter are captured accurately and the electronic health record properly reflects the services that were provided.” — From an EHR Intelligence article on the benefits of clinical documentation improvement.

This focus has given rise to CDI specialists, a career that combines precision with critical thinking. Wikipedia gives a brief overview of what’s required: “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. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance Portability and Accountability Act [HIPAA] in the United States.”

When you consider that just ICD-10-CM involves more than 71,000 codes and how a hospital’s accuracy determines payer funding amounts and speed to revenue, you get a feel for the requirements of the job. And these codes are updated regularly. SearchHealthIt gives an overview of some 2019 changes: “The 2019 ICD-10-CM codes became effective on Oct. 1, 2018, and should be used for discharges and patient encounters from that date through Sept. 30, 2019. The 2019 guidelines were approved by the four organizations that comprise the Cooperating Parties for ICD-10-CM: The Centers for Medicare & Medicaid Services (CMS), the National Center for Health Statistics (NCHS), the American Hospital Association (AHA) and the American Health Information Management Association (AHIMA). The update contains 279 new codes and 143 revised codes and removes 51 codes, bringing the total number of codes to 71,932.”

Of course smart coding does help your hospital’s bottom line, but there’s more at stake. As an article at ACP (American College of Physicians) Hospitalist makes clear, “after the documentation is translated into the alpha-numeric codes submitted in claims, the data are analyzed to generate results on quality and clinical outcome measures in addition to payments.”

The same article also emphasizes the clinician (or hospitalists) role in working with coding teams. “Their documentation drives and controls everything that happens subsequently. Clinician CDI participation has three components: awareness, competence and collaboration.” Next, the article explains how the coders should work with the clinicians: “The clinical documentation specialist’s (CDS) role is, through medical record review, to capture pertinent clinician documentation while the patient is in the hospital. The next step, if needed, is to submit a request (query) to clinicians for clarification or additional documentation that would permit assignment of a more precise code. A CDS should conduct verbal discussions with clinicians whenever possible for more effective communication.”

And the CDS works a bit like a detective collaborating with the clinician. An article posted in The Guardian gives this insight: “My job mainly consists of reading through patients’ medical records—that’s everything that documents their hospital stay, from admission to discharge — and converting the information into alphanumeric codes using the ICD-10 and OPCS-4 classifications that the NHS then uses to set resource-management targets and receive reimbursement for treatment and care. Rules can be very complex and strict; it’s essential to keep up-to-date with policies and procedures. I think of myself as a detective; collecting, arranging and presenting evidence. For a history graduate, too awful at chemistry to fulfil my aspirations of becoming an ophthalmologist, it’s perfect. My coding career was an accident — a logical but ambitious step for a medical records filing clerk.”

If it sounds like a lot of work — it is. And many physicians are feeling the crunch. As an EHR Intelligence article notes, “A 2016 study from the American Medical Association (AMA) found that for every hour clinicians spend with a patient, the clinician then spends two hours on EHR documentation. Providers spend 27 percent of their work time on direct patient interactions and about 49 percent on EHR documentation.” The same article makes the point that in addition to smart, well-trained coders, “workflow documentation tools, such as pre-structured data elements, can also help to improve the quality of documentation while reducing the time spent charting and free up more opportunities to connect with patients and devote attention to their needs.”

We will continue to keep an eye on clinical documentation improvement as diagnosis and treatments evolve and policies and regulations adapt to the changing healthcare landscape. R1 takes speed to revenue seriously for hospital clients and at the heart of it is the integrity that CDI brings. For this reason, more than one of our service areas focus on CDI solutions, including Underpayment Recovery, Medicare Reimbursement, and Professional Services where we provide certified coders among other experienced medical team members to supplement hospital staffing needs.

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