Precise, complete, trustworthy, and timely documentation is critical to validate services provided, reduce risks, and improve patient care. With accurate clinical documentation, a medical billing company can help healthcare providers submit valid claims for reimbursement. If the information presented in the documentation does not provide a complete and accurate picture of the care received by a patient or does not support the billing codes, claims may be denied.

While electronic documentation is designed to increase both the quality and the utility of clinical documentation, it has resulted in large volumes of data and repetitive information. Maintaining documentation integrity while using automated EHR functions has become a major challenge for physicians. The Centers for Medicare & Medicaid Services (CMS) is simplifying documentation through its Patients over Paperwork initiative, but the focus is still on quality improvement. However, there are two things physicians should know about clinical documentation improvement (CDI):

  • CDI is not about just ICD-10 or CPT coding, but about ensuring that the medical record provides an accurate picture of the patient encounter.
  • CDI is not about providing more documentation – it’s about improving the quality and value of clinical documentation and better using this documentation to improve care.

Here are 5 strategies that experts recommend to improve clinical documentation in 2020:

  • Tell the patient’s story: The clinical record should tell the patient’s story in as much detail as is required to ensure seamless care. The documentation should communicate the patient’s past and present health information and medical treatment to other clinicians. Providing a summary of previous history and its impact on treatment options would be useful. The documentation should also convey the physician’s thought process about the patient’s care. For instance, accurately portraying a patient’s comorbidities is essential to ensure high-quality care for chronic diseases.
  • Use the SOAP documentation method to add narrative to the record: Instead of just checking boxes in the EHR, physicians can still use the traditional SOAP documentation to add their narrative to the record. The Rheumatology article notes that including the physician’s assessment and rationale would prove valuable to support the plan of care and demonstrate medical necessity for services provided.
  • Supplement E/M templates with free-form text: The medical record should indicate the correct E/M level that best describes the service provided. The nature of the presenting problem and the complexity of medical decision making are key considerations when choosing the E/M level. However, standard EHR systems feature documentation templates for the four E/M office visit levels that make it easier to get higher levels when the medical necessity might not be there. Experts recommend supporting EHR templates with using free-form text to describe the nature of a visit. For instance, even one or two lines can add detail and integrity to the note by stating what is unique to that patient visit.
  • Think twice before using the EHR copy-paste function: The ECRI Institute warns that poor use of copy-paste can affect clinical documentation quality by:
    • Introducing new inaccuracies
    • Facilitating the propagation of inaccurate information
    • Allowing the creation of internally inconsistent notes, and
    • Resulting in lengthy notes that may obscure important clinical information
    • Best practice is to perform a mindful review to ensure that the documentation is not redundant and reflects the current situation
  • Capture new findings and relevant information: In addition to pertinent facts, physicians need to document new findings and impressions. This includes diagnosis, positive exam findings, pertinent negative exam findings, and significant abnormal test findings. Physicians need to use their clinical expertise to translate findings into diagnoses (www.hospitalist.com). This may result in more clinical documentation and the use of more diagnostic codes.

The ICD-10 official guidelines address coding for uncertain diagnoses, with different rules for inpatient and outpatient coding. Hospitalists can offer an uncertain diagnosis for a condition that is suspected as being present: If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. In the ICD-10 guidelines for outpatient settings, CMS states: “Do not code diagnosis documented probable, suspected, questionable, rule out, compatible with, consistent with, or working diagnosis or similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for the encounter or visit, such as symptoms, signs, abnormal test results or other reason for the visit.”

The goal should be to ensure clear, accurate, concise, documentation that conveys the patient’s story and treatment plan to other caregivers. The physician should make sure that fellow clinicians reading the note understand their thought process and why those conclusions were drawn so that they can continue to provide the right care. A monthly or quarterly documentation self-audit of a select number of patient records can help identify any issues and drive improvement.

Excellent documentation is important for superlative patient care, compliance, medico-legal, utilization review, and accurate reimbursement. Outsourcing medical billing and coding is a practical option to ensure accurate ICD-10 and CPT coding to submit accurate claims and improve cash flow.