HealthOctober 12, 2022

Five ways to improve clinical documentation and bridge the gap between coders and physicians

As hospitals and health plans increasingly rely on patient data from the EHR for quality reporting, analytics, reimbursement, and other initiatives, the importance of clinical documentation integrity grows. 

To facilitate the accurate documentation of patient encounters, many organizations have implemented clinical documentation integrity (CDI) programs. The Association of Clinical Documentation Integrity Specialists (ACDIS) offer this application of its Code of Ethics regarding CDI programs, “CDI policies should be designed to promote complete documentation regardless of whether reimbursement is affected. The goal of CDI work is to promote accurate documentation and subsequent coding."

The role of a Clinical Documentation Integrity Specialist in patient care

Those familiar with risk adjustment from the perspective of a health plan organization might be unfamiliar to where a Clinical Documentation Integrity Specialist (CDS) fit in the scheme of a patient visit. CDSs are generally clinicians that have worked beside providers, collaborating with the care team. CDSs are very comfortable condensing pertinent patient information to the provider’s attention for them to address relevant conditions. CDI programs work with providers before, during, and after encounters to accurately capture their patients’ burden of illness. CDI can assist in teasing out the clarity needed to code conditions to the highest specificity.

Given that a recent study showed providers spend about 16 minutes during a 15-20 minute encounter documenting in the EHR, CDI becomes an invaluable support for harried providers. CDI programs can digest large amounts of information to facilitate the provider by prospectively highlighting what really needs attention during their visit with the patient. Concurrently, the CDS can help the provider with code assignment and retrospectively CDSs can help providers with situations when coding and clinical logic misalign.

CDI bridges the gap between clinical and coding language

One of the most pervasive challenges that coders and physicians face is that they speak two different languages. A coder’s workflow is based on what is documented in the physician’s note within the medical record. Coders can only code if there is enough information in the record to document a diagnosis. Physicians aren’t taught to code and don’t understand the coding language.

CDI programs can be helpful bridges to close this gap. Let’s take the example of a stroke. If the patient had a stroke a week ago, providers may consider that a recent stroke. But for the coder, the patient has a “history of” stroke as soon as he or she leaves the hospital. 

This miscommunication not only causes frustration for providers, it can also become a compliance issue. The Office of Inspector General (OIG) targets areas where clinical practice differs from coding practice.

CDI can be helpful in this case because the clinical documentation specialist has both clinical and coding experience and can pull those two languages or two worlds together. The CDS can clinically validate whether a condition exists and if the specificity is in the record to capture the diagnosis.

Population health and social determinants of health are two areas that could become compliance concerns. While providers are becoming aware that there are non-medical conditions that impact people’s health and are beginning to ask patients about them, if the information isn’t in the note, the coder can’t code it. So, while providers may be asking questions to get the information, oftentimes it’s not in a format that the coders have access to.

Gaining physician buy-in for a clinical documentation integrity program

But what if a physician doesn’t believe in the CDI program?

Physicians don’t receive training on clinical documentation in medical school so it’s common for some providers to resist these programs as an added hassle and unnecessary work.

Building relationships with physicians

What I’ve found in my experience implementing CDI programs is that relationship building is vital before physicians can buy-in to the process. I need to have a relationship with that provider very similar to when I was caring for the patients as a nurse, so that they trust that I am going to do what they've ordered me to do. I’m a support person, so to speak. That role doesn't change a whole lot when it comes to CDI. The clinical documentation specialist is still a support person.

Holistic approach to coding

If physicians trust that support person, it’s easier for them to understand that the CDI specialist is there to ensure that the care the patient receives is documented and the query is justified. Where a coder can only look at a singular encounter, a CDI specialist can look elsewhere in the chart to pull out information that may indicate another condition. For example, if a CDI specialist sees a patient is receiving dialysis, he or she can ask the physician, was this an emergency or is this long-term due to end-stage renal disease?

The key is not to ask leading questions. The work is not to only find the diagnosis but to find the information in the note that supports that diagnosis.

Cross-checking and validating diagnoses

Having the validation of the diagnosis and the supporting clinical indicators is also helpful for health plans. Once it’s determined the condition was present in the past and you have supporting information, a health plan organization could potentially use it as a basis of a query to the provider to ask whether the condition is still valid or viable. And if that is the case, the organization can ask the physician to please include any valid or viable conditions they addressed in the note for the upcoming visit so that they can better understand the treatment plan or what the provider saw that supported the patient’s diagnoses.

Five strategies for improving clinical documentation compliance

Whether your organization is just thinking about creating a clinical documentation improvement program or struggling with compliance issues, here are five best practices for success:

1. Do the pre-work before launching a CDI program

Review a sample of records to find a few areas to focus efforts on for measurable change. Show how improving documentation in these areas would benefit the patient, practice, or population. Educate providers before establishing a program. Clinicians need to understand the administration values their skills and time, and there is also value in the program. Physicians and coders need to find a way to work together and work smarter. 

2. Find a physician champion

Having a respected physician who understands the goal of the program is “the golden chip” to launching a successful program. This person supports the mission of a CDI program and can promote it to colleagues.

3. Review the record prior to a patient visit

A clinical documentation specialist can review the medical record in advance of the office visit to assess for suspect or outstanding conditions and compliance opportunities. This prospective view is a little more forward thinking than traditional coding and lends itself to having a more clinical person in the role.

4. Set up processes

Establish a policy that calls for a CDI specialist to review the bills with targeted codes prior to submission to ensure the code is appropriate. If there is a question, the CDI specialist can determine if the documentation supports this diagnosis, or not and changes the code as needed. The ultimate goal is to accurately capture the patient’s story and resources provided during their visit within the boundaries of compliant coding.

5. Leverage technology as part of your CDI program

Having the proper tools in place can help enable more efficient and accurate documentation, starting at the point-of-care. Provider-focused intelligence tools, embedded in the EHR, can streamline search and guide physicians to the most specific diagnosis code. 

Quality clinical documentation is foundational for healthcare organizations who need coded data to improve quality reporting, ensure accurate reimbursements, and drive better patient outcomes. Wherever you are on your journey, the Health Language team at Wolters Kluwer can help! Reach out to today to speak to an expert.

This article is adapted from an interview with Amy Campbell conducted by RISE, published June 13, 2022.
Read the Whitepaper: Improving Clinical Documentation Accuracy and Efficiency
Amy Campbell
Clinical Documentation Improvement Manager, Health Language
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