Book excerpt: Defining clinical documentation and coding standards in the revenue cycle, integrating real-time auditing, part 2

by Elizabeth Lamkin, MHA, ACHE

To reinforce formal documentation education provided to physicians and staff, open chart auditing and real-time education is needed. Effective facilities typically have a CDI program staffed with trained professionals to concurrently audit every open chart and query providers to obtain clarifications and additional documentation when needed.

Placing CDI staff on the clinical units to audit chart documentation in real time and personally interact with physicians and other clinical staff, often helps with education effectiveness as well. The CDI specialist can query the physician to explain why the documentation does not meet criteria or does not really tell the story of the patient’s condition.

A common query from CDI specialists to the provider is, “Why?” Why can’t the patient be cared for in a lower level of care? Why are you ordering this? Why did you say the patient has sepsis? The CDI specialist should then ask for documentation justifying the care. This interaction is an extremely effective form of education for all involved.

The CDI staffing schedule should mirror physician patterns of rounding to get face-to-face. Once a physician goes back to the office, or is off for seven days as many hospitalists are, it is much harder to get a response to queries. In other words, simplify things for the physician by aligning schedules and staff location. For example, if your facility has a large surgical program, consider assigning a CDI specialist in the surgical department.

The CDI and nursing staff have a role in physician order fulfillment. Once an order is written, the CDI and nursing staff can audit to be sure the order was delivered, the service was performed, and results or a note were included in the chart. This reduces delays in treatment and discharge, and the physician gains confidence in the hospital systems.

CDI specialists do not work alone. They form a team with case management (CM) staff and the physician advisor/s (PA) for concurrent documentation audit and correction. The CM advises the physician on status, the CDI specialist ensures the documentation reflects the status and care, and the PA is there to support CM and CDI if there is conflict with a physician or clinical staff. The PA can take advantage of every interaction to transform potential conflicts into teaching opportunities.

For example, a patient scheduled for an outpatient surgery on the inpatient-only list, according to CMS, OPPS final rule, 2016. The surgery scheduling department checks the inpatient-only list and notifies the physician that case management (CM) is going to review for status. The surgery department then alerts registration, which notifies the CM, who checks to make sure all requirements for the inpatient surgery are met. The CM advises the physician on correct status and, ideally, the physician follows the CM’s advice. The CDI specialist checks the documentation for compliance and coding and queries the physician if documentation is incomplete. If the surgeon refuses to change or complete the documentation, the CDI specialist escalates the issue to the PA. The PA contacts the physician and explains the reasons for inpatient status and additional documentation. The surgeon completes the documentation as requested. If these steps are completed, it is clear to coding and billing what claim to drop without requiring a bill hold and clinical review.

The CDI specialist, CM, and the PA are able to gather real-time feedback on whether the EHR is user-friendly, and they can report findings back to the executive team and IT through the medical record improvement committee. In some cases, problems with the EHR are simply user error or lack of training, and the CDI specialist can play a role in teaching providers to use the EHR.

Throughout this process, the HIM department works with CDI and supports physicians through functions such as timely transcription and ensuring chart completeness. Together, CDI and HIM will audit the chart for appropriate orders, signatures, and all required elements of the medical record. This includes ICD-10 coding and documentation to monitor ICD-10 compliance. HIM has traditionally been responsible for the organization of the medical record but now must have a collaborative relationship with IT and the EHR vendor to ensure the record works well for all stakeholders.

Finally, HIM will also review the medical record upon discharge for completeness. The next step is to code the record for payment. If all the previous steps in revenue cycle have occurred correctly—required forms are in place, patient status is clearly documented with a care plan, and discharge status is clear and accurate—then the coders should have all the elements needed for accurate coding. There should be very few physician queries from HIM coders if coding is clearly supported through documentation. Getting all of this right while the patient is in the hospital will facilitate accurate coding and produce a clean claim to avoid back-end corrections and delayed billing.

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.