Improved documentation: leveraging staff training, benchmarking, technology, and process change for accurate payment

Healthcare Financial Management, April, 2008

One strategy is to change the overall message, Minick says. In the past, Boswell and other hospitals used reimbursement as a sort of drumbeat. Boswell now is paying more attention to the ways in which documentation affects physicians.

"It's important for us to say to physicians, 'Your patients are sicker, older, more complex. This is your chance to have the empirical data to show that. So when outside agencies profile you, it's clear what type of patients you are truly taking care of,'" she says.

Minick adds: "In our conversations with most of our physicians, we are able to point to such things as, 'Here's a case mix that moves from x to y with accurate and appropriate documentation of the patient's condition.' It was hard at first for us to learn how to speak to that focus, as opposed to continuing the easy thing and talking about reimbursement. But our approach now is to talk to physicians about appropriate documentation of the patient's condition."

At St. Vincent Health, the focus of conversations is similar. "In physicians' quickness to complete a medical record, they may not clearly and succinctly document the acuity of a patient, which may end up reflecting poorly on them and their care," says Funsten.

Therefore, the concurrent documentation program at St. Vincent Health concentrates on helping physicians meet their own external quality indicators. For example, the program illustrates how coders use the information in physicians' progress notes to distinguish between a complication and a normal or an expected outcome of a procedure. A frequent example is blood loss during implant surgery, which is not a complication.

"There are certain parts of the coding guidelines that, as much as you'd like to think are black and white, really are gray areas that are not clearly defined," Funsten says. "From a non-clinical point of view, you wouldn't have the medical school training or necessarily know the statistics that define what is to be expected following a particular procedure."

St. Vincent Health enlists the expertise of its medical director, who is an internist and hospitalist, as well as surgeons to get input and clarity.

"We want to be sure we don't inappropriately code a normal outcome of a procedure when in fact it's a complication," he says. "But sometimes it's a fine line. The important piece of this is having the avenues to go and get the information and advice."

The struggle is to get physicians to document in a diagnostic language, not just in the clinical language they are familiar with. What concurrent documentation programs try to do is bridge the gap between the clinical and the coding world.

That's where physician champions or advocates come in.

* The Importance of Training

Concurrent documentation programs rely heavily on training physicians about the demands for greater specificity in their documentation, not only to adhere to new Medicare coding rules but also to provide an accurate picture of their patients for outside profiling agencies and to point out that the documentation that works in the private practice environment doesn't always translate to the hospital setting.