Clear. Complete. Concise. These three Cs describe ideal patient record keeping, which is why they are among the key reasons to implement a clinical documentation information (CDI) program into your rheumatology practice. Not only will CDI help you accurately document the full picture of each patient’s clinical status, but it also promotes high-quality care and translates your services into coded data that often lead to higher reimbursements.
Attention to detail in documentation is critical for a number of reasons. Rheumatologists are sometimes their own coders, and their documentation isn’t always being checked for specificity by someone in the back office. When they have a dedicated coder, rheumatologists’ notes need to be specific, thorough and readable so the coder can easily identify the accurate codes to use.
“CDI is all about the patient and accurate documentation,” explains Tammy Combs, director of health information management practice excellence and lead CDI nurse planner at the Chicago-based American Health Information Management Association (AHIMA), a society dedicated to advancing professional practice and standards for the health informatics and information management community. “You’re looking at the complete picture of what’s been diagnosed with the patient.”
Under Scrutiny
Now more than ever, Ms. Combs says, payers are scrutinizing services delivered by every healthcare provider in every healthcare setting—not to mention that quality healthcare measures are being linked to physician reimbursement. Unlike the past, more questions are now being asked about:
- Patient outcomes;
- Expected outcomes vs. observed outcomes;
- The level of care provided;
- The evidence used to support a diagnosis; and
- The treatment prescribed to resolve or stabilize the condition.
Ms. Combs says the best way to address such questions is through accurate and thorough documentation. Rheumatologists need to document patient information with the highest level of specificity, and they must ensure there’s evidence to support their diagnosis and treatment.
How CDI Helps
CDI provides education on how to achieve high-quality documentation. One of the first steps is for practitioners and coders to speak the same language.
“Sometimes, clinician speak is different than what a coder would need to see in the patient’s chart [in order] to translate a diagnosis to a specific code,” Ms. Combs says, adding that ICD-10 includes combination codes that better represent a higher level of specificity. “The program provides education to providers or physicians as to the detail needed in documentation so coders can take it out to the highest level of specificity.”
