How to create clinical documentation improvement workflow in your medical practice
In an era of pre-payment reviews, denials, and post-payment recoupments, physician documentation is paramount. The specific words physicians use to capture the patient’s story can make or break revenue integrity. It’s important to pay attention to these words and understand how payers interpret them. Having a formal process for clinical documentation improvement in revenue cycle management can help. This process—sometimes referred to as ‘CDI’ for short—ensures physician documentation correctly represents the patient’s clinical status, thereby promoting accurate and complete medical coding.
Want to implement a CDI workflow in your revenue cycle but not sure where to begin? Consider the following clinical documentation improvement steps:
1. Know your ‘why.’ What are your top reasons for denials? How can improved documentation benefit patients and revenue integrity? This information will help you prioritize cases for CDI reviews. You can also prioritize documentation related to quality metrics that improve population health and drive shared savings under value-based payment programs. Leverage the analytics capabilities in your electronic health record (EHR) to take a data-driven approach to CDI.
2. Identify who will perform the CDI reviews in your medical practice. For example, it might be a nurse with medical coding experience, a medical coder with CDI training, or both working collaboratively.
3. Decide whether CDI reviews will be prospective or retrospective. Ideally, a clinical documentation specialist would review the medical record prior to the patient’s office visit to alert the physician to suspect or outstanding conditions and other information that might be important for medical coding and particularly for hierarchical condition category (HCC) coding. HCC coding plays an important role in risk-based or capitated payments. A proactive approach to CDI gives physicians the opportunity to clarify information while the patient is in front of them and long before a bill is ever sent to the payer.
When done retrospectively, CDI specialists typically perform random reviews to ensure critical details were documented. Here are some examples of what they might look for:
Condition for which medication was prescribed was listed in the medical record.
Documentation clearly indicates why the physician appended a CPT modifier.
Evaluation and management (E/M) code was medically necessary based on the patient’s presenting problem(s).
Time was clearly documented for all time-based codes and when reporting an E/M code based on time.
4. Decide when to query physicians in your medical practice. Establish a decision-tree protocol that clearly describes when a CDI specialist will—and won’t—reach out to a physician for clarification. Will it be for certain diagnoses? Certain procedures? A combination of the two? This helps narrow the focus so as not to overwhelm physicians and CDI specialists alike. For example, you shouldn’t query for clinically insignificant findings; however, you should query in cases where documentation:
Confirms clinical indicators but doesn’t specify the condition.
Describes a potential cause-and-effect relationship between two conditions.
Includes treatment but no diagnosis.
Is illegible (including cases where copy and paste makes information confusing or conflicting).
Supports clinical evidence for a higher degree of specificity or severity.
5. Provide ongoing physician education. CDI specialists in your medical practice should strive to educate physicians regularly on the importance of documenting the following:
Aspects of a patient’s medical history that may play a role in medical-decision making.
Existence and status of all comorbid conditions a physician considers when deciding a course of treatment.
Individualized, patient-specific details particularly when using boilerplate documentation templates and auto-generated notes. Encourage physicians to ask themselves, ‘What makes this patient unique?’ or ‘How can I differentiate this patient in some way?’ Similarly, if copying and pasting information in the electronic health record, physicians should validate the information ‘copied forward’ is accurate and relevant to today’s visit.
New clinical developments and any pertinent findings.
Social determinants of health and their potential impact on treatment and medical-decision making.
6. Measure success. Here are some revenue cycle management metrics to help measure the effectiveness of your CDI process:
Agreement rate (how often the CDI specialist and clinician agree on a query)
Denial rate
HCC capture rate
Query rate
Response rate
Review rate (how many clinical records have been reviewed)
Satisfaction (provider and patient)
If you don’t see an improvement in these metrics at first, stick with it and potentially tweak your clinical documentation improvement steps. Over time, you’ll see the benefits in terms of data and revenue integrity.
Conclusion
When you focus on CDI in your medical practice, you enhance revenue integrity and so much more. Your medical coding becomes more comprehensive and accurate, leading to a much higher quality revenue cycle that promotes financial sustainability. Learn how edgeMED can help and be sure to check the Healthy Snacks blog for more expert insights, best practices and industry trends.
