Victor Freeman, M.D., Regional Medical Director for Nuance Healthcare Solutions, spoke at a recent CME event on the importance of clinical documentation for every provider.
Here are 10 tips from Dr. Freeman’s presentation and a panel discussion with LG Health/Penn Medicine providers:
Remember: Clinical documentation drives coding – and coding drives payment. If you don’t take documentation seriously, it will come out of your pocket.
Provider pay is increasingly tied to performance. Poor performance ratings sometimes reflect weak documentation more than the quality of care delivered.
Make sure you get credit for the true severity of your patient’s conditions. Be specific. For example, there is a big difference between “thin” and “severe protein malnutrition.”
Be thorough. Document all diagnoses associated with your patient. Capturing secondary diagnoses allows for risk and severity adjustments, which help to more accurately reflect your patient’s condition -- and the quality of your performance.
It’s not just about you. Failure to accurately capture all of your patient’s diagnoses also affects performance ratings for your group and hospital.
Now that the ICD-10 transition is complete, expect increased scrutiny on documentation. Good, thorough documentation is your best protection.
Proving medical necessity is essential. A code isn’t enough. You must explain why the patient needs that particular procedure at that particular time.
Make sure you can support every diagnosis on a patient’s chart, using clinical criteria or a clinical evaluation. This will help you defend the chart in the case of an audit.
Don’t stretch the truth. Exaggerating the severity of a patient’s condition will get you in trouble. Physicians do go to jail for fraudulent billing.
The Clinical Documentation team is not here to police you. They are here to help you be successful. Questions? Contact Jean E. Banzhof, MSN, RN, Manager, Clinical Documentation Improvement, 544-4426 or firstname.lastname@example.org.