July 17, 2018

Physician Clinical Documentation: The Lifeblood of the Revenue Cycle

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The “right documentation” is the central pivot point to the revenue cycle

 

Physician clinical documentation plays a critical role in any overall healthcare delivery model, including the life of the revenue cycle, which drives reimbursement for quality medical care provided to patients. The revenue cycle is defined by the Healthcare Financial Management Association (HFMA) as "all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue."

In other words, it is a term that encompasses the entire life of a patient account, from creation to payment. Accurate and complete clinical documentation is germane and instrumental to effective communication of patient care, which serves a myriad of purposes, including the achievement of quality-focused, outcomes-based, patient-centered, cost-effective healthcare delivery. Material to the transformation in value-based models of healthcare is the ability of providers to demonstrate the delivery of the right care at the right time for the right reason in the right setting with the right clinical judgment, medical decision-making and thought processes, with the right plan of care displaying the right documentation.

The “right documentation” is the central pivot point to the revenue cycle, fundamental to the entire spectrum of the patient encounter, extending from the time of outpatient scheduling of care or inpatient presentation for care in the hospital to the time the patient encounter is coded, the bill is dropped, and payment received or denied by third-party payors.

 

Focusing Upon Communication of Patient Care

Clinical documentation improvement (CDI) initiatives have existed for over 10 years, with most facilities either utilizing consultants or home-growing their programs. As a consultant myself, I subscribe to a unique perspective on how best to design, implement, seek engagement of physicians as constituents, and continually enhance the value of any initiative to improve the quality in communication of patient care.

The clearly limiting factor preventing achievement of optimal CDI outcomes is the narrow spectrum of focus in most programs upon diagnosis capture associated with either revenue optimization or reporting of hospital-acquired conditions, patient safety indicators, or severity of illness and risk of mortality. While I am certainly not downplaying the value and necessity of accurately capturing and reporting all clinically relevant diagnoses as a key part of CDI, the profession is overlooking the potential to make an overwhelming positive sustainable contribution to the patient care model.

Each hospital’s revenue cycle encompasses virtually every aspect of patient care, including scheduling, authorization, physician orders, patient registration, patient care documentation, charging of services, coding, and billing. Yet, CDI’s main thrust of focus is upon capturing diagnoses in an unrelenting quest to “maximize” revenue, which is measured on a “gross” level versus the more accurate, valid, and reliable “net” patient revenue basis. Any businessperson realizes that what matters truly is the amount of billed revenue that turns into real cash, the backbone to ongoing continual business operations.

 

Aligning and Integrating with the Revenue Cycle

In my present role as CDI manager, I am finding much success in aligning present clinical documentation initiatives with the revenue cycle, along with integrating practices and processes that directly support the revenue cycle in driving gross revenue to net patient revenue. My vision of CDI embraces the notion that attaining meaningful improvement in documentation requires an expanded vision of the medical record. Extracting full value from the medical record requires CDI as a profession to recognize the crucial role the clinical documentation improvement specialist plays in affecting positive change in the communication of patient care. It was quite troublesome to hear several CDI specialists recently mention that their primary role is to secure diagnoses and move onto the next chart, not collaborating with case management and utilization review staff to ensure a complete and accurate picture of patient care. The industry must overcome the pitfalls inherent to clinging onto the current silo approach consisting of processes that are narrowly defined in scope.

Breaking down the traditional silo approach to CDI requires an ongoing commitment to expanding the vision of the record as a real communication tool for the physician, the patient, and all the ancillary healthcare stakeholders integrally involved in the care of a patient. I have been tasked with transforming my hospital’s established CDI program to one that thrives upon collaborating with case managers in the emergency department, staff on the regular hospital floor, utilization review staff, and denials and appeals staff.

Collaboration is the process of two or more people or organizations working together to complete a task or achieve a goal. Practically applying collaboration in our CDI program, CDI staff are committed to becoming more proficient in understanding and identifying best practice principles and standards of clinical documentation representing sound communication of patient care. The CDI staff subscribes to a realistic approach to chart review that incorporates elements of documentation supportive of physician clinical rationale and medical necessity for admission, beginning with documentation in the ED and progressing to the history and physical that forms the basis for hospitalization decisions by the physician.

The physician’s ability to describe the patient’s story in vivid detail, representing the true clinical acuity, is germane to establishment of medical necessity. Our CDI staff hold dear to their heart the essential duties to review the record holistically, working with physicians collaboratively as coaches in disseminating and sharing techniques and practices of documentation that succinctly yet vividly capture and reflect the patient’s clinical acuity, plus accurately report the physicians’ clinical judgment and medical decision-making for both the need for hospital level of care and supportive diagnostic conclusions in the form of definitive and/or provisional diagnoses. The case managers and utilization review staff regularly refer concurrent accounts for CDI to review as a central part of our CDI program, through which they identify cases presenting challenges in meeting medical necessity, often containing contradictions in documentation, excessive copying and pasting, or progress notes that fail to depict the progress of the patient.

To this end, the collaborative goal is to enhance the communication of patient care for all those dependent upon the record to effectively carry out their responsibilities as care providers and all ancillary support staff. Closely aligning with the revenue cycle function to optimize performance requires this expanded approach to CDI.

 

Transforming CDI

Transforming CDI first requires the recognition that the profession needs to push the reset button. No longer can the profession rest on its laurels and accept current processes of CDI as the standard for affecting positive change and sustainability in real improvement in documentation. Understanding and treating the medical record as a communication tool beyond diagnosis capture is a sound starting point for transforming CDI into a powerful force supporting the revenue cycle. I call upon the two associations representing the CDI profession to jump-start the current model of CDI into the 21st century. The present model of CDI is like a stale loaf of bread, marked down for quick sale for a reason.



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Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM

Glenn Krauss is the physician documentation improvement manager at University Medical Center of Southern Nevada. Glenn has more than 20 years of experience as a professional in the field of health information management (HIM). Previously, he held executive and consulting positions, including revenue systems manager, CDI director, director of case management and revenue enhancement, director of HIM, and data quality manager with major U.S. hospital and health systems. Glenn is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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