November 21, 2014

Clinical Documentation Improvement in the Medical Practice

By Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CEMC, CPMA, CCS-P, CDIP Certified AHIMA Clinical Documentation Improvement Practitioner AHIMA-Approved ICD-10-CM/PCS Trainer

As I continue on my journey assisting hospital systems and medical practices transitioning to ICD-10, it has become evident that clinical documentation is at the core of this transition. But as I read so many articles about ICD-10 initiatives and clinical documentation improvement, I wonder if we really grasp the true impact. Many feel it is only important as a hospital initiative, but that really is not true. Other pieces I have read focus on auditing, which is only a small part of clinical documentation improvement (CDI). I call it a movement to improve clinical documentation, improve support for quality of care, and support medical necessity for the procedures and services reported on claims.

The patient medical record, whether in a hospital or medical office, tells the story of the patient encounter from beginning to end. Clinical documentation improvement goes beyond good compliance practices of auditing and monitoring by placing emphasis on working toward improving documentation and coding on an ongoing basis. In reality, documentation begins and ends with the practitioner (physician and non-physician), and this should be a medical practice initiative and a top priority – especially with the looming migration to ICD-10. But keep in mind that it is not just about ICD-10 in the medical practice. It should be about documenting evaluation and management (E/M) services for accurate payment and supporting the complexity of each patient treated while accurately reporting procedures and other services when medical necessity supports the diagnosis code reported. Clinical documentation improvement is a very significant part of maintaining compliance in the medical practice, whether the practice is small, large, or hospital-owned. The larger the practice, the more complex the issues become.

The three key elements in developing and maintaining a CDI program are: 

    1. Assessment
    2. Development
    3. Monitoring and Managing

A  CDI program should be customized to meet the needs of each individual medical practice, as one size does not actually fit all. CDI is a process that must feature a step-by-step approach.

An experienced CDI practitioner should be involved with the development process to ensure that all appropriate steps are taken to build a comprehensive plan, including:

Step 1: Conduct a baseline review (assessment phase).

Step 2: Develop a protocol or process for managing CDI (development phase).

Step 3: Develop a query process (development phase).

Step 4: Educate all practitioners and applicable staff on the CDI process and purpose

           (development phase).

Step 5: Begin implementation of the CDI program (monitor and manage).

Step 6: Reevaluate the program and make improvements (monitor and manage).

Step 7: Provide ongoing education and training (monitor and manage).

So, what does it mean to conduct a baseline review in a medical practice? The baseline review is similar to an impact assessment. Some key questions that should be asked as part of the baseline review are:

  • Have you reviewed the current electronic health record workflows and templates?
  • How do physicians document and code services?
  • What tools are used internally for coding?
  • Do physicians have coding assistance, and if yes, by whom?
  • How does the documentation and coding flow into the billing process?
  • Is there a process for auditing and monitoring documentation on a routine basis?
  • Is there a query process in which documentation or coding can be clarified?

In addition, a baseline coding and documentation review (audit) should be conducted for each physician and/or non-physician practitioner to determine current levels of compliance.

Once you have performed this baseline assessment, you can begin to build the CDI process and develop the query protocol. 

Currently I am working with medical practices performing assessments. When auditing records for compliance we tend to look at the patient encounter a bit differently. We are looking at what is documented and asking the following question: Does it support the coding and follow the carrier policies? When performing the baseline assessment and performing a documentation review, it is also important to look at the complexity of the patient more closely and determine what information is missing or unclear in supporting the condition(s) being managed. 

Current workflows and templates should be reviewed to determine if they work for the practitioners, not against them. I am finding that the practices that do not customize their workflows and templates to meet the need of their practitioners could actually contribute to a lack of documentation. I am also finding that about 80 percent of the time we need to go back and revise the workflows and templates to make it easier for the practitioners to document in order to meet quality of care initiatives and support documentation and coding.

The other alarming issue I have been uncovering is that some practices use the E/M analyzer tool in their electronic health record to select their E/M levels. I think these are excellent tools, but even I can document a perfect level 4 or 5; what is missing from these tools is the ability to determine complexity of the patient. For example, if the physician documents a detailed history, expanding on the problem with a focused examination, and writes a script for a new problem (say, rhinitis) for an established patient, does this support a level 4 (99214) visit? Absolutely not. 

But the analyzer tool identifies medical decision-making as moderate, and technically it meets the definition of a level 4 (99214) visit. But according to the Centers for Medicare & Medicaid Services (CMS) Comprehensive Error Rate Testing Program, medical necessity is the “overarching criterion” for selecting a level of service. These tools do not have the ability to assign medical necessity.

The point I am trying to make is that this is an opportunity to educate practitioners on how to use these tools correctly. Another key step to take is to have your CDI specialist or practitioner review and monitor the documentation on a routine basis to ensure that the levels are being selected accurately and medical necessity is supported.

When looking at coding tools, I uncovered one large medical group using the National Correct Coding Initiative (NCCI) edits from CMS when there are so many electronic tools on the market that can not only identify bundled services, but also assist with coding, modifiers, and even medical policies in some cases. Using the NCCI tables takes more time and is more cumbersome and inefficient. These are essential coding tools in all medical practices. So there are opportunities to improve the process inexpensively. 

I have found over the years that some practitioners simply do a better job of documenting than others. I think many practitioners are now feeling more comfortable with coding and documenting their E/M levels, procedures, and services. However, many still struggle with modifier usage, particularly when it comes to modifiers 25 and 59. Also, I see issues with unbundling and lack of clarity in the documentation for conditions managed during the patient encounter. So there is yet another challenge. 

Some of the practitioners I have assessed select their diagnoses from the problem list, which does not always include the conditions being managed most often. Then some other practitioners miss reporting chronic conditions that affect the treatment of patients. Specificity is not always documented, which is problematic in ICD-10. We need to help physicians document smarter, not harder. 

Many medical practices audit coding and documentation once annually – and for some practitioners, that is not enough. Once the baseline assessment is complete, a schedule for auditing and monitoring each practitioner who needs guidance can be developed to not only meet compliance, but to improve clinical documentation and support medical necessity. 

I find that most medical practices have a workflow from coding to billing, but in many cases efficiency and accuracy can be improved with changes in workflow. In addition, it is important as part of CDI to develop a query process to check coding and documentation prior to claim submission. An electronic query process is ideal, and many electronic health records have some capability to build it, but even if you don’t have electronic tools, a system can be developed. 

Once I complete an assessment. I write up an executive summary with recommendations for development of the process – an essential step in creating a successful program. I find that if we encourage CDI in the medical practice, documentation will improve not only in the clinical setting, but in the hospital documentation as well. 

Implementing a healthy CDI program can be a successful endeavor with support from executive leaders and physician champions, with help and guidance from CDI practitioners and specialists.

Coming up next month: Step 2 — Building the CDI Process in the Medical Practice.

About the Author

Deborah Grider has 32 years of industry experience and is a recognized national speaker, consultant, and American Medical Association (AMA) author who has been working with ICD-10 since 1990. She is the author of Preparing for ICD-10, Making the Transition Manageable, Principles of ICD-10, and the ICD-10 Workbook, among many other publications, for the AMA. Deborah has worked as a practice administrator for 12 years and has been helping large and small organizations prepare for ICD-10 since 2009. Deborah holds multiple coding certifications with AHIMA and AAPC and is an AHIMA-certified clinical documentation improvement practitioner, as well as a healthcare consultant with Karen Zupko & Associates.

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