Physician Advisor’s Corner: Clinical Documentation

By Andrew Maigur, MD

It’s imperative as physicians to realize that Clinical Documentation Integrity is a quality initiative. Accurate, high-quality clinical documentation improves communication, increases recognition of comorbid conditions that are responsive to treatment, validates the care that was provided, and shows compliance with quality and safety guidelines. As a fellow physician, I am positive that I would not have to persuade you to want to take excellent medical care of your patient.

Here are four reasons why you should be invested in optimal documentation:

• It is in the patient's best interests. We owe our patients an accurate medical record.
• It is in the provider's best interests. Not just the hospital's, but your quality metrics (LOS, readmissions, SOI-Severity of Illness score, ROM-Risk of Mortality score, PSI-Patient Safety Indicator, post-op complications) are also derived from observed–to–expected risk–adjusted metrics (abstracted from coded data). Your quality measures are publicly available for review on Medicare’s Physician Compare (https://www.medicare.gov/physiciancompare/) and may guide potential patients’ choice of provider.

• It is also important that physicians understand the process of audits and denials and the financial impact on the hospital. At this time, most physicians have not felt any repercussions from a recovery audit contractor (RAC) denial, but the impact on a hospital is very tangible. Not surprisingly, the top 10 RAC-denied diagnoses are often similar to the top 10 queried diagnoses. Hence, good documentation done concurrently will only help to improve the outcome of a RAC audit. CMS issued Transmittal 541 that allows Medicare Administrative Contractor (MACs) and Zone Program Integrity Contractors (ZPICs) to deny “related claims.” This means when the facility receives a denial if an admission is found to not be medically necessary, they can also deny the corresponding physician claims.
• It is in the hospital’s best interests. The hospital is being judged by certain quality measures, and rewarded or penalized for, in turn. If our hospital looks substandard on Hospital Compare (https://www.medicare.gov/hospitalcompare/search.html) patients and payers may avoid our services. If our sites of care look bad in value-based purchasing, they may lose money. No margin, no mission.

Some of you might think, “I don’t care about the hospital’s reimbursement.” I would ask, is it fair that the hospital provides state-of-the-art care for your sick patients and incurs soaring costs of care but does not receive the appropriate reimbursement? Absolutely not!

I would ardently encourage you to consider CDI and Coding as your allies to facilitate accurate, codable, clinical documentation to reflect the excellent care you provide to our patients!

Back to the July 2020 issue of Premier Pulse