Guest Post: Complete and accurate clinical documentation is the future of healthcare

by Fran Jurcak, RN, MSN, CCDS

What can you can do to improve your program? How can you put some of your CDI strengths into better practice and re-examine your weaknesses to determine what you can do to tweak it and make it a more successful program? There are numerous opportunities for program improvement every day. Let’s look at a few of the common areas of CDI program improvement begin practiced today.

For many years, many programs were driven by what we did from a Medicare and reimbursement perspective. When you look at what is currently best practice in the documentation world, it really is about addressing documentation for more than just financial issues. We want to make sure that we capture the true severity of illness (SOI) of the patient. We want to know which conditions were present on admission (POA) and how the patient’s care progresses through to discharge. It is all this documentation that helps to determine the final payment, the determination of the final DRG, and it is going to determine what the hospital and physician profiles on a variety of measures.

Certainly, medical necessity is driven by what is documented, and when we have clarity and consistency in documentation, CDI programs can impact length of stay concerns, also. If the CDI program includes all these concerns, and we have clear documentation for all of the conditions that were treated while the patient was in the hospital, then you’re going to be compliant, and it’s going to help you avoid being audited by not only by RAC, but whatever other auditing body may want to review any of your records.

When you look at what truly is the line of severity, or the line of SOI as I like to call it, you’ll see that what we’re really trying to do through documentation improvement is ensure that all of the conditions being treated are clearly and appropriately identified. In other words, we all know that there’s a little bit of a discrepancy in the language and wording used in the medical world as opposed to the language used on the coding side. It is (was) this discrepancy that was kind of why we all started having CDI programs in the first place.

You don’t want to over-document conditions that aren’t really being treated. You don’t want to have the facility reimbursed for care that wasn’t part of the patient’s clinical picture. Conversely, you don’t want to have situations arise where, because of the inaccuracy or lack of specific documentation, you lose the opportunity to get the appropriate codes, get the correct patient profile, and get the right reimbursement.

Take that just a little step further. Appropriate documentation of the SOI of the patient is going to support quality and core measures scores as well. Those are the pieces of the documentation that then drives profiling and they are the pieces of documentation that impact where the case mix index goes, the average of all those relative weights of all those DRGs required to support the appropriate length of stay, and that too gets reflected in hospital and physician profiles.

As we look to the future of healthcare and how facilities and physicians are reimbursed, and what’s happening with their payment structure, it’s becoming more and more clear that there’s going to be some comparison between what’s happening in the hospital and the documentation in the hospital, and what the physician might be billing for that visit.

We want to make sure that the documentation those are as accurate as possible to compliantly get what we deserve and support where we are billing.

Editor’s Note: This post was excerpted from the audio conference “Clinical Documentation Improvement: Strengthen your program and protect against denials,” presented on Thursday, January 27. Jurcak, at the time of this article's original release, was a manager with Wellspring Partners, a division of Huron Consulting, and had been a nurse for 25 years. She has a strong clinical and educational background having served as a professor of nursing for many years.