Physician Documentation Improvement – Why, How, and Where do I start?

Posted by Dave Cowley on Nov 10, 2017 10:45:41 AM

It seems like a simple concept:  Document what is wrong with the patient, and what you are doing about it.  Yet, despite clear and highly visible impacts to any healthcare organization, the war for improvement rages on in every provider office across the country.  The two hot spots most often acknowledged are impacts to revenue and regulatory compliance.  We will talk about the importance of those factors – but I would also submit that clean and actionable patient information is a critical piece of our nation’s healthcare strategy.  More on that in a bit.Documention Improvement.png

Where do you start whether you are a physician, administrator, or cog in the revenue cycle machine?  Here are a few key strategy points to consider:

Retrospective audits of documentation:  These reviews are important to uncover whether all required information for coordination of care and billing support is captured.  This can be done through random sampling of the most problematic documentation areas (if you know what they are), but is most often more effective when focused on the highest volume diagnoses and/or top service charges for a particular physician or service line.

Communication process for deficiencies found in the documentation:  This can include a query process where the provider is asked for additional information in a non-leading manner.  If your EHR does not offer query functionality, put a system in place, but with HIPAA compliance in mind so that the complete record and information can be discussed/reviewed.

Develop a strategy for education and training:  This goes much deeper than just documentation improvement, as there is a continual stream of topics that need to be delivered effectively to the provider population in any healthcare organization.  MIPS, MACRA, E/M levels, ongoing ICD-10 education, patient experience, and of course documenting all of it clearly and completely.  Many organizations struggle with the cultural dynamic of training a busy provider.  If a plan and strategy is mutually agreed upon it will be much more effective when it is time to convey important details.  Sometimes this requires outside help or influence, and many organizations benefit from peer to peer style educational formats.

A few impacts of improved documentation include:

  •       Improved communication between your provider and revenue cycle staff
  •       Fewer claim denials/rejections
  •       Increased reimbursement (especially in the area of risk adjustment coding (HCC) and quality improvement programs like MIPS/MACRA)
  •       Better overall continuity of care and patient quality measures
  •       Fewer physician queries = less administrative time for providers
  •       Increased coder productivity = bills out the door more quickly

And finally, improved documentation of patient conditions and treatments allows for better visibility into the health of patients within our healthcare system.  Better visibility means better and more valuable analytics for population health management, disease tracking and treatment “best practices”, and development of strategies for earlier intervention and improved outcomes.



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Topics: revenue cycle management, Medical Practice Improvement, CDI