“Clinical documentation improvement is all about the quality, not just about the reimbursement,” said Jon Elion, MD, FACC, associate professor of medicine for Brown University, CEO of Chartwise Medical Systems, and practicing cardiologist, as he addressed a standing room only crowd Monday morning at AHIMA’s 2014 Clinical Documentation Improvement Summit. Elion’s presentation, adequately titled “Stories from the Front Line,” offered several insights into a physician’s way of thinking about clinical documentation.“If you pursue reimbursement, you will miss the high quality medical record, but if you pursue a high quality medical record the proper reimbursement will follow,” Elion said. This rings true for every type of healthcare facility that handles patients. If the documentation is there in the medical record, then the need for queries decreases and the reimbursement will be appropriate, Elion said. Legibility seems to pop up as a challenge whenever one talks about documentation. Some may think that this is only relevant in the paper record world, but that is not the case. Illegible entries in the electronic health record are present and growing at an alarming pace. What happens if a physician utilizes an abbreviation that is not commonly known? That note is illegible since no one else can interpret what the physician was documenting, and possibly won’t understand how the patient was treated. After spending decades as a practicing cardiologist, Elion says that physician clinical documentation training can be reduced to two words: “due to.” By adding those tiny little words to his documentation, Elion said that it changed his notes to mean so much more clinically, as well as provide the direct link to understanding his documentation. A physician must be taught the concepts of clinical documentation improvement (CDI) in order to realize any type of return on investment for the program, Elion said. A facility may think they have a great physician on staff that does a great job at answering all of his queries. However, when the HIM director starts looking at the queries, they notice that the majority of the queries are for the same disease process. This shows that the physician refuses to change his documentation style in order to capture the documentation up front, Elion said. HIM professionals should be able to use this type of information as a learning tool for the physician, and prevent a constant need to query the same documentation issue. An “inappropriate utilize,” a phrase Elion came up with, is a physician whose resource utilization does not match the severity of the patient’s documented illness. If there is utilization, then there should be physician documentation of the signs, symptoms, or disease that is appropriate for such resource involvement. In some instances, there may be a need to clarify the physicians’ documentation. However, CDI specialists should never query when there is no supporting clinical information documented within the medical record. When requesting “clarification” through queries, CDI specialists should make sure that if a computer program is utilized that there is human involvement and that the program is not capable of automatically generating queries to physicians. By using humans in the query process, it allows CDI specialists the ability to sort through the clinical information that a computer program may not visualize or recognize. Lastly, Elion reminded attendees that they should remember what the documentation is being used for. The complete, accurate coded data is essential for many things, including the improved quality of patient care, identifying and reducing medical errors, and clinical research. “Physician documentation is the cornerstone of accurate coding,” Elion said.
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