“The primary objective of clinical documentation is to assist doctors in the complex journey of portraying in standardized text formats complete clinical pictures,” says Michelle Dragut, MD, CCS, CDIP, a physician adviser for the Florida Hospital Association Management Corporation in Orlando. “All healthcare organizations depend on correct documentation.”

A price to pay

“Financial viability rests in accurate documentation,” Dragut says. “If it is not written, it did not happen. Correct reimbursement for hospitals is imperative in today’s world. You want to stay afloat and not be targeted for committing fraud or abuse.”

In 2007, the Centers for Medicare & Medicaid Services (CMS), in an attempt to reduce instances of overbilling and reimbursements for hospital-acquired conditions, began paying hospitals for treating only those conditions present and documented upon patient admission. CMS and other federal agencies have even more aggressively pronounced intentions to penalize improper payments due to inaccurate documentation. Contributing to the growing need for more accurate documentation are Medicare payment reductions legislated by the Patient Protection and Affordable Care Act, a CMS rule mandating the transition to ICD-10 and an expansion of post-payment auditing programs to ensure the government has not been overbilled.

In the past year alone, the Office of the Inspector General produced a report calling on CMS to crack down on improper documentation in EHRs and CMS reported to federal legislators that it will reduce Medicare payments to New York by more than $1 billion per year because its state-operated facilities overbilled the government by $15 billion for two decades. It doesn’t matter whether fraud is the intent. As Department of Health and Human Services’ Office of Civil Rights Director Leon Rodriguez, JD, said during a December 2012 conference hosted by the Healthcare Information and Management Systems Society, “Enforcement breeds compliance.”

“For too many years, some physicians got by documenting a minimum of details,” Dragut says. Now, CMS has sharpened its rhetoric: If you fail to properly document clinical care, you will pay the price.

New reasons to document

“In the beginning, clinical documentation improvement (CDI) programs were implemented to ensure accurate reimbursement,” says Melanie Endicott, health information management director for the American Health Information Management Association in Chicago. “We wanted to get paid what we deserved based on what we’d done. Now, there’s so much more to CDI than reimbursement.”

In the era of healthcare reform initiatives aimed at increasing transparency, enhancing the effectiveness of health IT tools and standardizing care according to evidence-based guidelines all for the purpose of achieving improved healthcare quality at lower costs, the negative consequences for inadequate clinical documentation are growing.

Provider participation in CMS’ physician quality reporting system, a value-based payment program that adjusts reimbursement rates according to quality indicators, is currently voluntary, but adjustments will apply to all providers beginning in 2015. Providers will no longer be able to simply submit diagnosis and procedural codes to maximize reimbursement when the program is fully implemented; they will need to prove they are following evidence-based guidelines. For instance, one quality indicator used by the Physician Quality Reporting System measures how often a provider administers aspirin to patients with ischemic heart disease. Even if providers within an organization consistently adhere to that guideline, reimbursement will suffer if they aren’t consistently documenting adherence.

State governments, the federal government and other entities also are increasingly using claims data to produce public report cards on hospital performance. This puts increased pressure on providers to not only engage in evidence-based care, but to demonstrate their efforts to patients and other business entities they work with. “There’s a new impetus to not only maximize reimbursement, but also to reflect quality,” says Marcia Brinson, MPH, manager of quality and patient safety improvement at the NewYork-Presbyterian Healthcare System (NYPHS) in New York City.

Strategies for improvement

Asked whether NYPHS was investing in additional CDI specialists, computer-assisted coding (CAC) software or natural language processing (NLP) products to address deficiencies in existing processes, Brinson answers, “All of the above.”

But NYPHS is not the only provider redirecting attention to CDI. A survey of 182 provider organizations, published in January by Orem, Utah-based healthcare market researcher KLAS, revealed that nearly 50 percent plan to invest in CAC software, 31 percent plan to invest in NLP products and 17 percent will require additional personnel to address CDI needs, which are largely driven by the transition to ICD-10 and Meaningful Use requirements, according to Endicott.

Of course, simply putting money into a CDI program alone will not improve clinical documentation. Effecting organizational change requires a concentrated plan that is frequently revisited and revised. NYPHS, comprised of 25 hospitals and 10 long-term care facilities, allows individual facilities to customize their own CDI programs, but they must demonstrate a plan for implementing protocols to standardize clinical documentation. Annually, the system hosts a CDI conference to allow staff from its member hospitals an opportunity to exchange notes and receive continuing education.

Perhaps the most important aspect of any CDI program is involving the documenting clinicians. The best way to do this is by observing what they’re doing at the point of care, according to Dragut. “When you do clinical documentation improvement, you are being most proactive at the time the doctor writes it down or, in the EHR world, when he strikes the key.”

The flow of health information follows a complicated course from the point of care to the billing department to a payer’s office or a reporting agency. Providers get frustrated when workflows are disrupted for no apparent reason, so educating those trained in clinical care on the implications of inadequate documentation is necessary, according to Endicott. “It’s having that conversation and providing some education to physicians about what this means for our bottom line and their bottom lines.”

Hospitals are undoubtedly beginning to take clinical documentation more seriously with their reputations and incomes at risk, but beyond dollars and bad reviews, improved clinical documentation can improve patient safety and outcomes. If a provider fails to document all facets of a patient’s disease, all treatment provided to the patient and all of the patient’s risk factors, the provider is putting the patient at risk for medical error, according to Dragut. “The details you include about your patient are never too much.”