For example, Ms. Combs points to a patient diagnosed with rheumatoid arthritis (RA) and a comorbid condition, such as congestive heart failure (CHF). She says rheumatologists need to document the CHF’s acuity level: Chronic or acute? Systolic or diastolic? How is the CHF affecting the patient’s RA? How are you modifying the patient’s treatment plan to help her progress while still considering the limitations imposed on her by the CHF? (Her cardiologist may prescribe walking on a treadmill for 30 minutes a day, but her RA prevents her from complying.) Likewise, you may have spent more time with this patient because of her comorbid conditions. At the very least, you may have read her cardiologist’s notes.
Improved Accuracy = Improved Care
By adding a higher level of specificity to your documentation, you are painting a more accurate, realistic picture of the patient’s illness level, which in turn, enhances quality of care and boosts physician reimbursement.
“Make sure you’re getting credit for chronic conditions that are impacting your patients,” says Ms. Combs. “[Payers] are not getting the true clinical picture of how sick patients truly are, because not all comorbid conditions are being documented. Once you understand the foundation of good, high-quality documentation, you’ll be successful in any setting.”
The ACR also encourages members to take advantage of Rheumatology Informatics System for Effectiveness (RISE) registry, which provides enhanced quality improvement capabilities by directly extracting data from your EHR. RISE is a Qualified Clinical Data Registry (QCDR) available for free to the ACR’s members, and participation in RISE according to CMS requirements will help you avoid the negative 2.0% Physician Quality Reporting System payment adjustment.
Carol Patton is a freelance writer based in Las Vegas.
