Summer reading: Defining documentation and coding standards in the revenue cycle, part 1
by Elizabeth Lamkin, MHA, ACHE
Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and sometimes vague rules. A facility’s revenue cycle plan should define the necessary education on documentation, when and how this education will be delivered, and how compliance with education will be reported.
It is difficult to hold physicians and other medical staff accountable for applying the rules if they are not educated on what the most current rules require. Physician engagement increases if education includes whydocumentation is so important and why it must be done correctly while the patient is still in the hospital. Physicians normally do not receive formal education or training on documentation to meet regulatory and coding criteria in their training programs or through continuing education; therefore, it is up to the hospital to stay current on regulations and documentation rules and to provide training to physicians.
Physician education can occur through medical staff channels such as section meetings, continuing education, or other channels specific to your institution. There are many external and online resources available. Internally the physician advisor (PA), case management (CM), compliance, CDI, and HIM departments are excellent resources for training on compliant documentation as relates to each perspective on the matter. Documentation education should be part of medical staff and independent licensed practitioner orientation as well.
After physician training, compliance with the documentation rules must be audited and reported with feedback to physicians to allow continual improvement. For example, the use of physician scorecards and case studies on denials allows physicians to see how they rank in the organization and demonstrates the results of good versus poor documentation.
As a part of the Ongoing Professional Practice Evaluation (OPPE), each physician should have an indicator for documentation compliance beyond just timely record completion, according to The Joint Commission, 2016. The Quality Assurance &. Performance Improvement (QAPI) typically supports chart audit for peer review and should work with members of the revenue cycle team, including the CDI and HIM departments to help provide feedback.
Clinical staff training should follow typical training methods to ensure clinical staff and their leaders understand their role in revenue cycle. For example, nursing has a role in documentation of skin care, continence, infusion, ventilator start/stop times, medications and reactions, and much more. Ancillary departments such as speech therapy provide assessments for diagnosis such as for dysphagia and then must clearly document if dysphagia is present or not. Consider all the disciplines that participate in patient care and how each will document on their area of responsibility to provide a complete medical record.
All of this documentation must be appropriate and available to the entire care team, especially the physician who is responsible for the overall health of the patient. The electronic health record (EHR) plays a huge role in this regard, as it’s the tool for documentation and communication for revenue cycle. To ensure the EHR is effective, information technology (IT), HIM, medical staff, and hospital staff must come together. Most facilities are either completely electronic or on their way to having all-electronic documentation. The IT department must engage with clinical staff and HIM to set up the EHR in a way that works for the staff who use the EHR, but also produces a comprehensive chart for use in billing and other administrative needs.
Further, regulatory and payer rules often dictate separate utilization review processes for Medicare, Medicare Advantage, and commercial payer patients; therefore, despite payer differences, a user-friendly, standardized EHR and systems for consistent documentation are essential.
Once training has taken place and the EHR is working well, it is time to put theory into practice. For all payers, documentation for coding and billing begins with the attending physician who writes the admission order and documents the patient’s ongoing condition and need for level of care.
Editor’s note: This article is adapted from The Revenue Integrity Training Toolkit by Elizabeth Lamkin, MHA, ACHE. Lamkin is CEO of PACE Healthcare Consulting and specializes in system development, quality and billing compliance. The views expressed do not necessarily represent those of ACDIS or its advisory board.