Although the Centers for Medicare & Medicaid Services (CMS) is simplifying documentation through its Patients over Paperwork initiative, clinical documentation improvement (CDI) did not go away. CDI is not about how to code in ICD-10-CM or the Current Procedural Terminology (CPT); instead, it is a huge part of the solution in maximizing the integrity of patient medical records to reduce risks and improve patient care. The goal of CDI is to ensure documentation always provides a complete and accurate picture of the care received by a patient in any setting for those who need to know what to look for in medical records and so they know how to ask for clarification and ongoing changes to the notes and comments provided by physicians.
In the office environment, the primary focus for physicians is to effectively convey through documentation the provider’s thought process regarding a patient’s care. For example, if the physician must consider co-morbidities when deciding the course of treatment, the existence and status of those conditions should be accurately documented in the medical record. Similarly, if aspects of the patient’s medical history play a significant role in the physician’s medical decision making, a brief summary of that history and how it affects treatment options or a note to reference previous history information can be included.
The CMS is streamlining the process to reduce some of the documentation burden associated with evaluation and management (E/M) services. For proper CDI, physicians can reference relevant previous visit documentation by date. Example: I have reviewed the history and exam documented in the previous visit note dated 1/5/2019, which are incorporated into today’s note, except for changes as documented below.
The current documentation structure in electronic health records (EHRs) was based on the 1995 and 1997 E/M guidelines. Specifically, EHR templates are commonly designed to anticipate and populate the history and normal exam findings related to elements that are nearly always addressed. The physician would then revise the findings to reflect any presenting abnormality. Some EHRs allow the physician to select, for example, the musculoskeletal exam and work through a stream of logic. To avoid shortcomings, practices can add some of the physician’s own narrative to the record. Even one or two lines from the provider can add detail and integrity to the note by answering all important questions such as, “What is unique to this patient at this visit?”
One might assume the new guidelines would be easier to implement, because they require less documentation. Most providers are familiar with using the subjective, objective, assessment and plan (SOAP) documentation method, and it can still be used rather than simply clicking boxes in the EHR. Although the history and exam can be somewhat standard, a brief description of the physician’s assessment and rationale will go a long way to support the plan of care and demonstrate medical necessity for services provided.
One key factor in a patient’s medical record is checking that the E/M level describes the true nature of the visit. Typical EHRs use common documentation templates with general, prerecorded statements for the four E/M office visit levels, regardless of the presenting problem. It’s always best practice to supplement EHR templates with free-form text that speaks to the nature of a visit. This would be like the paper note on which the relevant clinical historical components are summarized. These narratives present an individualized patient-specific chart note and prevent the physician’s note from looking the same from patient to patient.
Another important goal is to capture new developments and pertinent findings. With this may come a greater number of ICD-10-CM diagnostic codes, which can mean an increased need for detailed clinical documentation. Making the right code selection requires adequate clinical detail, and under ICD-10-CM, clinician documentation will ultimately translate into reimbursement gained or lost.
Remember, documentation of systems reviewed is significant, but a comprehensive, or eight-organ, system review is not necessary for every patient encounter. From a clinical documentation perspective, an initial presentation of a newly developed, undefined root cause evaluation may warrant a comprehensive review of potential findings. For follow-up visits and specific problem-focused presentations, only an examination containing relevant findings is recommended.
When it comes to clinical documentation improvement, access to all pertinent information is key for providers to create the best documentation and provide a complete picture of their medical decision making. Collaboration of all office staff is important for quality care; with detailed, accurate documentation, clinical analytics can assist in improving the decision-making process and help capture the development of complications before they begin. This will enhance overall patient care, improve risk management, reduce claim denials, advance audit preparedness and improve cash flow.
Under value-based care, understanding the link between coding to the highest degree of specificity, documentation, outcomes and reimbursement will be essential to physician practice success in 2020 and beyond. Proactively implementing a formal process for case review, provider queries and staff education will ensure that clinical documentation best practices are in place to support practice efficiency.
For questions or training on outpatient CDI efforts, contact the ACR practice management department at [email protected].