Value-based reimbursement is complicated, but measuring care quality is necessary to transition away from the fee-for-service payment models that many experts believe to be a driver of inefficiency and overspending in healthcare. To advance healthcare’s value-based transformation and maintain fiscal health, hospitals and health systems must meet more sophisticated clinical documentation requirements.

Reviewing encounter data is one method health plans use to determine value-based reimbursement. Encounter data is information documented by providers that indicates clinical diagnosis as well as the items or services rendered to treat the condition. The Centers for Medicare & Medicaid Services (CMS) began using encounter data in 2015 to calculate provider payments, and reliance on this data has only increased since. For 2021, CMS has proposed increasing the weight given to encounter data in risk score assessments by 50 percent. Errors in encounter data documentation, even minor ones, can result in claim denials, which delay provider payment and create more work for hospital revenue cycle staff.

“The diagnosis has to be correct and so does all the other data, and it needs to be reviewed by coders,” said Mike McMann, the vice president of client management for Conifer Health Solutions, during a recent interview with Becker’s Hospital Review. “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.”

While the importance of accurate clinical documentation is clear to hospital and health system executives, navigating value-based reimbursement remains a vexing challenge for many healthcare organizations. Hospital leaders looking to help their organization find success under emerging, value-based payment models have to understand how to streamline encounter data documentation while fostering engagement and collaboration among staff.

3 components of streamlined encounter data

Conifer has partnered with more than 660 hospitals, health systems, and physician groups to help improve value-based performance. Mary Bacaj, PhD, the head of value-based care at Conifer, detailed the three key components of streamlined encounter data in a recent conversation with Becker’s.

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.”

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.