By: Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, for ICD10 monitor
As you prepare for the newly announced Oct. 1, 2015, ICD-10 compliance date, now is the time to evaluate and redefine your clinical documentation value chain. A value chain is a series of activities that are performed in order to deliver a valuable product or service for the organization.
The clinical documentation value chain consists of physician documentation, clinical documentation improvement (CDI) program, and coding and compliance processes, with the end goal of developing an integrated and streamlined process that is focused on the integrity of the clinical documentation and cuts across the entire continuum of care, utilizing complete and electronic physician documentation methods. Value stream mapping is a lean-management method for analyzing the current state and designing a future state for the series of events or steps that take a product or service from beginning to end, and this you can do for your clinical documentation value chain.
Concurrent Physician Documentation with Patient Care Delivery
Physicians today are delivering patient care in a hybrid documentation world consisting of both paper and electronic clinical documentation that often falls short of completeness and the necessary specificity required for accurate coding, billing, compliance, quality reporting, and outcome analytics. However, this challenge can be addressed by leveraging the right technology. Speech recognition solutions allow hospitals and practices of any size to capture the physician narrative via dictation, improving the speed and accuracy of documentation, reducing transcription costs, and improving appropriate reimbursement due to the submission of bills that contain more complete documentation. Additionally, physician speech recognition is proven to accelerate electronic health record (EHR) adoption, improve physician satisfaction, and allows physicians to spend more time with their patients.
Aligning CDI Programs with Physician Documentation
Many CDI programs today focus on missing clinical documentation after the encounter, whether it is ambulatory, observational, or inpatient. As a result, physicians often see these programs as disruptive, time-consuming, and adding little value to patient care. Therefore, the goal must be to align the CDI process with the delivery of patient care, not afterwards.
To do this, the CDI team must work side–by-side with your clinicians to provide education, guidance, and evidence-based strategies designed to engage physicians in the CDI process with the goal of improving communication between caregivers, and capturing documentation that better reflects the severity of illness and treatment provided for each patient. This will lead to more accurate and efficient coding and appropriate reimbursement.
Coding and Compliance Process, Dependent on Effective CDI and Processes
Coding solutions are typically very labor-intensive and the onslaught of new codes (ICD-10) and incomplete physician documentation could make it very challenging to be successful for your coding team. It is important to evaluate whether your current clinical documentation and associated coding processes are designed to meet the needs for regulatory compliance.
An important factor to consider is that as ICD-10 and the shift to value-based purchasing, along with other critical compliance and quality reporting requirements, go into effect, the lack of accurate and complete documentation, specificity, and form (electronic vs. paper/handwritten) of the physician documentation will result in financial, operational, and compliance problems. If it is not documented, it cannot be coded. Therefore, as part of your information governance culture, it is essential to develop and document your Coding Compliance Policy and Plan, including creating your unique core clinical documentation set for coding compliance, which should consist of key source documents or designated core record sets for coding that will be used by your coding professionals as they conduct all the medical coding for your organization.
CAC in the Coding Workflow
Considering the complexities of ICD-10 adoption, many organizations are looking to Computer-Assisted Coding (CAC) solutions using Natural Language Processing (NLP) technology to suggest codes for validation. While this technology is important, it is only one link in the value chain.
Handwritten progress notes not only cause challenges for coders to decipher and access the information they need but are unusable by a CAC solution. Conducting a CAC-readiness assessment using the core clinical documentation set for coding compliance that you developed, along with the AHIMA CAC toolkit, to evaluate the percentage of electronic clinical documentation will provide insight as to whether this type of solution will help your coders become more efficient.
“Collect Once and Use Many Times”
This should be the mantra of the future state design of your clinical documentation integrity value chain. The current state typically consists of siloed workflows that do not include technology enablement, which is labor-intensive. When considering the future state of your organization, it is important that the clinical documentation integrity value chain upturn these silos, creating cross-functional workflows that leverage new technology wherever feasible.
Utilize Technology and Physician-focused Approach to Address Clinical Documentation Integrity
Look for technology solutions that streamline and map together all the processes and sub-processes that make up the entire value chain, and create a more seamless and integrated approach where accurate physician documentation, CDI, coding and compliance, billing, and quality reporting are a natural result of the clinical documentation process. One way to accomplish this is to integrate your physician dictation and speech recognition solutions into your EHR strategy. A clinically driven approach to CDI creates complete and compliant documentation that drives more accurate reimbursement, compliance, and quality reporting on a real-time basis.
As you create the future state design of your organization’s clinical documentation processes of the value chain, it is important to follow the critical path of your clinical documentation integrity value chain from pre-admission though the close of the encounter and final coding and billing. This will enable you to find new opportunities and creative approaches to streamlining workflows and developing innovative ways to leverage your technology investment throughout your organization and across the continuum of care.
- Your ICD-10 transition strategy should be a multi-pronged approach that includes: 1. Physician-generated clinical documentation, 2. A CDI program, and 3. Coding compliance processes and solutions that include a defined core clinical documentation record set for coding compliance.
- Success requires focusing on the beginning of the process, and ensuring your physicians are engaged and empowered with the tools to help them capture high-quality documentation from the beginning, in their preferred workflow, and that is tightly integrated with the EHRs.
- Deploying a clinically focused CDI approach that engages your physicians with evidence-based strategies, education, and technology will provide them the tools they need to ensure documentation is clear and accurate from the moment the patient enters the hospital. This promotes better communication between caregivers, especially during critical transitions, and the resulting documentation better reflects the true severity of illness and risk of mortality of each patient.