Documentation Improvement: 7 Criteria for High Quality Clinical Documentation

Dorothy Steed

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Clinical documentation is the foundation of every patient medical record. People who document in records should meet clinical documentation standards. The record supports the severity of the patient's condition, assessments and evaluations leading to diagnoses and treatment management. Without strong documentation, it becomes difficult to support the medical necessity of services provided, opening the door for additional information requests, down coding, or denial of services. 

Additionally, in situations where legal action has been initiated, the record will provide the support needed by the provider to justify management and billing. If the record contains vague and ambiguous language, or is missing key information, this advantage is significantly compromised, and may lead to a costly negative outcome. 

Coders need high quality documentation to determine coding quality and accuracy, and cannot assume a diagnosis unless documented by the provider. Every regulatory agency is placing heavier emphasis on clinical documentation. As the industry moves toward value based medicine and blended payments, rather than fee-for-service, providers must become more focused on the documentation. The advantage really is in the details.

Course Objective:

The granularity and accuracy of the ICD-10 code set is supported by quality clinical documentation. It is anticipated that payers will increasingly become less flexible in allowing non-specific codes. The use of unspecified codes will likely lead to rejected claims if it is possible to report the more definitive condition. In most cases, unspecified should not be reported unless there is clear evidence to support the inability to report the detailed option.

Is your E & M level supported in the documentation? If you have never experienced scrutiny of your billing patterns by payers and other entities, you may not be aware of weaknesses that lead to recovery of funds or other costly consequences. Your documentation will be key in supporting diagnoses, service codes and acuity of the patient.

It is not just payers who engage in audits. Others include State medical boards, Qui Tam and possible reporting of questionable practices by patients. Does your billing patterns and documentation stand up under reporting scrutiny? This presentation will review areas in which you may not be as strong as you think!

Course Outline:

  • Review points of high quality evidence based clinical documentation
  • Review of criteria that all entries in a patient record should include
  • Impact of documentation on coding and claims
  • Impact on audits and ability to defend an audit
  • When an audit is initiated, the completeness of documentation becomes critical in the ability to support what you have reported.  
  • Let's take a look at areas in which weaknesses are often found.   

Target Audience:

  • Coders, billers
  • Revenue cycle, physicians
  • Mid-level providers, nurses,
  • Claims follow-up professionals
  • Managers
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Speaker: Dorothy Steed,

Dorothy Steed is an Independent Healthcare Consultant and Educator in Atlanta. She was a Medicare specialist for a large hospital system and a physician audit supervisor for another hospital system, with 39 years of experience in healthcare. Additionally, she is an instructor at a state technical college in Atlanta, provides auditing & training in both facility and physician services, and has been a speaker at several healthcare conferences. Ms. Steed has written articles for several medical publishers and served as a contributing author for medical billing and coding training material. She writes online courses, and is an AHIMA certified ICD-10 trainer. Ms. Steed is credentialed in medical coding, medical billing, medical auditing, utilization management, healthcare management, healthcare compliance, clinical documentation improvement and patient accounts. She has served as a participator in multiple audits. She holds a Bachelor degree with a major in business and minors in both criminal justice and sociology.