Outpatient Facility Coding Alert

Hint: Check out these unique clinical documentation concepts.

Every day, your providers tirelessly strive to ensure their documentation is legible, reliable, complete, and timely. You encourage them to work with all of the necessary ICD-10-CM and CPT^® requirements and the current government quality measures. But what happens when their clinical documentation still falls short?

In her webinar "Navigating Changing Healthcare Environments Through Clinical Documentation Improvements," Rhonda Buckholtz, CPC, CPMA, CRC, CDEO, CPC-I, CHPSE, COPC, vice president of strategic development for Eye Care Leaders, shared some helpful strategies to help you boost your clinical documentation improvement (CDI) know-how.

Master These Unique Clinical Documentation Concepts

In her presentation, Buckholtz shared 22 unique documentation concepts she identified within ICD-10-CM. Templating these clinical concepts is a strategic way that ties back into patient care and simplifies the process for clinicians, according to Buckholtz.

Some of these clinical concepts include, but are not limited to the following:

• The type of condition
• Temporal factors
• Caused by or contributing factors
• Symptoms, findings, or manifestations
• Localization or laterality
• Anatomical location
• Associated with
• Severity
• Episode
• Remission status
• History of - including family or patient
• Morphology.

Buckholtz also researched CPT^® codes and developed documentation concepts for CPT^®, which mirror the ICD-10 concepts. These concepts include, but are not limited to the following:

• Type
• Anatomical site
• Size
• Number
• Time
• Complexity
• With or without.

Takeaway: If you engage with the clinician and work on these documentation concepts with their patients and the conditions they are treating, you can start to use the concepts in a meaningful way, Buckholtz said.

"We found out that we were able to be able to meet or exceed documentation requirements for compliance, for meaningful use, for documentation, for quality measures, for E/M levels, or surgical procedure documentation," Buckholtz added. "It actually began to reduce the administrative burden for physicians."

Education is Key Element to CDI Success

Along with working on those documentation concepts and templating strategies, we must teach our resources, scribes, techs, front desk staff, why what they're doing is important and the impact it has, Buckholtz said.

Use your ancillary staff to provide support for the provider, Buckholtz added. "You can take a lot of the administrative burden off a physician - teaching them these key concepts and working with those steps."

Also, teach the staff why it's so important to get the information, where it's being pulled from using your tools and technology, and use the resources you have through your products, Buckholtz said. As you follow these steps, you can start streamlining your measures.

"You can actually institute some cost-saving measures that help reduce that administrative burden," Buckholtz added. "At the end of the day, you're capturing everything that's necessary to really meet those points and that information for increased patient satisfaction and patient engagement."

Make Sure EMR Info is Accurate, Timely

One common challenge you may face with your clinical documentation is based upon electronic medical record (EMR) dependency.

"Sometimes we forget the reason why it's important to document something, and we start to carry in a whole bunch of information that has no relevance," Buckholtz said. "That can get us in trouble in an audit, but it also makes it very hard to have a meaningful patient encounter because you have to weed through a lot of information to get to what really was going on."

Example: Buckholtz offered an example from records she audited where the brought forth documentation didn't match the current documentation.

"I was auditing a medical record, and in 'health history,' it said the patient had been sober for three years," Buckholtz said. "But in the [history of present illness] HPI, it was documented that they were back to drinking two to three drinks a day. Those don't marry up."

Takeaway: Review any and all information you pull forward in your EMR.

"When you're dependent on that EMR and you just pull it forward without reviewing it or without clarifying what's really important for that patient encounter, you do a disservice at the end of the day," Buckholtz said.

Pose These Vital Questions to Stay Accountable

Before you implement any new process, whether a tool, technology, procedure, or policy, you should always ask these five crucial questions, according to Buckholtz:

Question 1: Is the solution compliant?

"If it's not compliant, you don't want to touch it," Buckholtz said. So, make sure the solution you're looking at follows any legalities, medical policies, and rules that are in place.

Question 2: Are we implementing the technology in full scope?

There are a lot of patient engagement and documentation solutions available, according to Buckholtz.

"Take a look at it [the solution] and make sure that it isn't fitting just one tiny, little piece of what you're trying to accomplish," Buckholtz added. "But, that it's actually going to meet your overall goal at the end of the day."

Question 3: What happens if we miss a step?

Ask yourself: If one person misses one step, what will happen? Where will that take me? Then, build an action plan to make sure this doesn't happen, Buckholtz added.

Question 4: Does my staff have the skills necessary to pull off what's being asked of them?

"You want to make sure your staff has the skills levels necessary to actually be able to perform the jobs that you need them to do," Buckholtz said.

Question 5: What is our audit process?

Any process you implement must have an audit process, or it will not be complete.

"Whenever you implement anything new, you want to figure out what your audit process is going to be," Buckholtz cautioned. "How are you going to know that you are successful?"

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