In the wake of COVID-19, physician practices faced a myriad of challenges creating a contactless and consumer-friendly patient experience, ramping up telehealth services, and transitioning non-clinical staff to work from home. Given these priorities, it’s understandable that clinical documentation improvement, or CDI, didn’t see much attention during the first half of 2020. However, as providers shift from triaging day-to-day patient flow issues to focusing on financial resilience, CDI can be a critical initiative that not only increases reimbursement revenue but also enhances the patient experience.
Now that COVID-19 is beginning to plateau and patients are returning for “in person” visits, providers can once again turn their focus to CDI to achieve the host of benefits it offers. By focusing on quality clinical documentation, such as preventing medical errors and reporting more accurate data to facilitate care-based initiatives related to population health and care coordination, it can help maximize reimbursement by ensuring coding and billing is as complete and accurate as possible. In an era where value-based care is becoming more pervasive—and will ultimately replace fee-for-service models—CDI has become a “must-have” rather than just an additive service.
Across all specialties, medical codes can have as many as 1,000 unique changes in a given year. In cases such as the coronavirus pandemic, coding and billing rules change to reflect market needs. Most recently, rules were altered to add COVID-19 code and billing requirements in order to allow telehealth to be more accessible and affordable.
While medical school may train physicians about coding so they can bill insurance in an appropriate and timely manner, it rarely focuses on CDI. Clinical documentation is essential to many aspects of a physician practice’s success—many of its components impact both reimbursement and patients’ care plans, such as Hierarchical Condition Category (HCC), severity of illness and risk of mortality. CDI enables providers to pinpoint deficiencies in current clinical documentation so they, along with revenue cycle staff, can be better educated, thus fostering more accurate work and capitalizing on opportunities to optimize payer revenue.
While improving CDI can result in major benefits, it’s not a simple or quick-fix endeavor and requires dedicated time and resources. A successful and thorough CDI program must be built with these components and best practices in mind:
1. People: Develop a dedicated team that truly understands the ins and outs of clinical documentation.
If any group that touches clinical documentation doesn’t have the necessary expertise, they’ll be less proficient, inaccurate and more likely to cause bottlenecks or errors within the workflow. Each task is important and interdependent on the rest of the workflow, which requires a team that maintains avid awareness of the many commercial payer and CMS updates made throughout the year.
2. Processes: Leverage a standardized workflow to seamlessly connect every task that touches clinical documentation.
All hand-offs between clinical documentation, coding and billing must be quick and accurate; therefore, end-to-end workflows should be built on proven best practice processes. Examples of best practices include pre-visit CDI reviews to support improved capture of HCCs and quality measures, post-visit CDI reviews of complex cases to support improved charge and coding capture and denial CDI reviews to enable a better medical necessity appeal process.
3. Technology: Couple talent and processes with the right technology.
CDI consists of many highly detailed tasks such as reviewing multiple dates of service across the longitudinal patient record and evaluating the record against complex and varying payer quality program documentation requirements. Supporting CDI with the right technology can significantly expedite your workflow and simplify your team’s tasks. Look for CDI technology that automates tasks with speed and accuracy. It should foster the most complete and accurate patient medical records and should ensure the most precise and comprehensive coding is submitted to payer and data-collecting organizations. The solution should also include a strong analytics platform and allow for monitoring and management of key metrics to focus efforts on top documentation opportunities.
Eliminate undercoding, overcoding, and reporting – Find opportunities by comparing your hospital’s billing data to data from similar facilities. Industry specialists have access to appropriate data sets and can make comparisons to offer suggestions for improvement.
Clinically validate high-risk diagnoses – With the current climate for denials, it’s crucial to thoroughly document and support high-risk diagnoses within the patient’s medical record. Ensure robust CDI education for providers so they understand how to prevent future denials.
Collaborate with the coding team – Frequent meetings with coding and CDI staff ensure an aligned work environment with everyone supporting the same goals. The two teams should regularly discuss areas of opportunity; for instance, coding may need a certain diagnosis more specified in documentation or CDI may see a way to gain additional revenue. A carefully written standard operating procedure will help facilitate a culture of positive collaboration.
Use diagnostic terms with the highest level of specificity – Precision in diagnosis and language is key. Examples include acute, chronic, left, right and bilateral. Many diagnoses have differing reimbursements depending on the severity of illness, risk of illness or expected length of stay. Greater detail supports full reimbursement.
Audits – Perform regular audits of medical records to ensure the team is capturing accurate and complete documentation for all patient records as well as identifying ways to increase reimbursement and improve patient care.
CDI will only become more important as our healthcare model continues to shift to value-based care. The right solution should deliver substantial ROI and pay for itself by pinpointing new opportunities for both patient care and financial improvements. Evaluating solutions and finding a partner who not only delivers the right technology but also provides the optimal workflow and expertise to help achieve every financial and clinical benefit of CDI is key. Only then will you be positioned to succeed and thrive in today’s new and challenging environment.
Brian Smit is an SVP, Physician Advisory Solutions and Clinical Operations at R1.