Updated on: October 30, 2017

Clinical Documentation Integrity Reduces Frustrations that Come with Change

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Original story posted on: October 31, 2017
CDI seen as a key solution to meeting regulatory policy changes.

One thing is inevitable this time of year for all of us in healthcare: change is in the air. You either thrive amid it or hide, but even those best at hiding ultimately cannot escape. The question I often ponder is this: why hide at all?

Each year we are hit with myriad changes in areas such as coding, quality measurements, and payment polices, just to name a few. And in the wake of these changes, we are left to struggle on how to adapt. Only the strong survive.

And let’s face it, we are up to our necks in administrative burdens. This year is no different. There is one major way we can make effective changes in our practices that will enable us to succeed once and for all, and the solution is clinical documentation integrity (CDI).

CDI is the key to all improvements, and it helps make us ready for the next big issue. While we wait for the final rule on fee schedules, or how the changes may be applied, or what’s next for quality, there is so much we can do to be ready in our practices and our facilities. Here’s some tips on helping you be prepared for any changes that may come your way:

  1. Run a practice management report for your most frequently seen conditions. Figure out the conditions you see the most.

  2. Prioritize that list and match up any chronic or comorbid conditions that contribute as well.

  3. Pull the clinical indicators (you can get them from your specialty society in most instances) and any evidence-based information you can find, such as that provided by the National Institutes of Health (NIH) or the Centers for Disease Control and Prevention (CDC).

  4. Review your templates to determine if are you capturing the treatments, parameters, and other items found in the policies.

  5. Review your intake forms: do they capture all the information you need for the conditions you see the most? Think about those chronic comorbid conditions that can affect your decision-making processes.

  6. Review your patient education forms, and make sure they are up-to-date.

  7. Work with your vendors on patient re-engagement activities.

Once you do this, tie all these elements together. If you work on your top 10 conditions, revise your templates for evidence-based medicine, and work to clean up your intake forms, you will hit not only coding guidelines, but also quality measures (no matter what they end up being).

You will experience fewer rejections, have stand-up documentation for easier appeals, and produce some amazing documentation that goes a long way in truly describing each patient’s clinical condition, which now becomes a win-win.

If we work on strategy to take the administrative role out of healthcare and instead focus on documenting for the actual clinical conditions, we can easily get to the point where the amount of changes that hit our practices each year will just be a small blip on our radar. This is where we need to head for the future advanced payment models and initiatives coming our way. The implementation of CDI will help carry you forward.

Program Note: For more information on this subject listen to Rhonda Buckholtz today on Talk Ten Tuesdays at 10 a.m. ET. Register to listen.
Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, COPC, CPEDC, CGSC

Rhonda Buckholtz is the vice president of practice optimization for Eye Care Leaders. She has more than 25 years of experience in healthcare, working in the management, reimbursement, billing, and coding sectors, in addition to being an instructor. She is a past co-chair for the WEDI ICD-10 Implementation Workgroup, Advanced Payment Models Workgroup and has provided testimony ongoing for ICD-10 and standardization of data for NCVHS. Rhonda spends her time on practice optimization for Eye Care Leaders by providing transformational services and revenue integrity for Ophthalmology practices. She was instrumental in developing the Certified Ophthalmology Professional Coder (COPC) exam and curriculum for the AAPC. Rhonda is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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