Foster Collaboration and Support Clinicians
Streamlining and improving the accuracy of encounter data documentation is a team effort. To enable successful collaboration, leadership should make an effort to break down communication silos between coders and clinicians. Oftentimes, coders may catch an inaccuracy on the backend, but never communicate with the documenting physician directly about the issue. Facilitating two-way communication between coders and clinicians through a Clinical Documentation Improvement (CDI) Program can proactively address this before a claim goes out to the payer.
When communicating corrective actions, conversations should be framed around the premise that documentation errors undermine the great work the individual physician is doing.
“We put together charts that show the great work the physician is doing, but also that this work is not all showing up in the documentation,” Ms. Bacaj said. “We tell them they’re not getting the credit for the work they’re doing.”
When encounter data is documented correctly, you get a clean claim, which results in accelerating payment and the elimination of additional rework. It’s vital to make sure all encounter data is accurate from the very beginning.
Mr. McMann outlined a hypothetical scenario in which a physician may not fully capture encounter data. If a pulmonologist sees a COPD patient that also has hypertension and diabetes but only documents the pulmonology services rendered, the documentation will not reflect an accurate picture of the patient’s severity of illness and risk of mortality. If the patient’s hypertension and diabetes aren’t reflected in the documentation, neither will the full breadth of the work the physician is doing.
“If the pulmonologist is prescribing a new medication, they have to take all of the patient’s relevant conditions into account,” Mr. McMann said. “If this doesn’t show up in the documentation, then it’s a missed opportunity to show the payer that the physician was engaged in oftentimes complex and chronic care management.”
Physicians want to focus on direct patient care, not documentation. However, physicians are also exceptionally driven individuals who want to be excellent at what they do. Making the case that documentation is an accurate record of their performance, quality of care provided, and use of resources can help generate physician engagement and compliance.
Worth the Lift
Integrating new processes and technologies to streamline and improve the accuracy of encounter documentation will naturally come with its own challenges–providers may initially be resistant to feedback and training on any new technology platform takes time. Once that work is done, however, physicians should experience less administrative burden, improved claims accuracy, and more timely claims adjudication.
“There may be an initial heavy lift, but ultimately this results in reduced administrative burden and physicians getting the credit they deserve for the great work they’re doing,” Ms. Bacaj said.