Keys to improve clinical documentation

Primary care providers in outpatient settings, where patient encounter volumes tend to be higher and more routine, offer an ideal avenue for understanding and influencing overall patient health. Recognition of the pivotal role that outpatient clinicians and documentation play in meeting value-based care objectives is driving support for clinical documentation improvement (CDI) programs in the physician practice setting. 

Why CDI?

Outpatient CDI efforts reinforce coding to the highest degree of specificity by educating clinicians and staff on evolving documentation requirements. The benefits of outpatient CDI include improved patient risk assessment, reduced claim denials, audit preparedness and improved cash flow. Outpatient CDI programs can also aid in clinical quality measure documentation under reporting programs like the Merit-based Incentive Payment System (MIPS). 

CDI programs may focus on a variety of areas including evaluation and management coding, CPT procedure codes, ICD-10 diagnosis codes, hierarchical condition categories or any combination therein.

Foundations for success

Understanding the link between documentation, outcomes and reimbursement will be essential to physician practice success under value-based care. Implementing a formal process for case review, provider queries and staff education can proactively ensure that clinical documentation best practices are in place to best support practice efficiency. 

Getting started

One challenge physician practices face is identifying resources to lead documentation improvement initiatives on behalf of the organization. Outside assistance is an option practices may turn to for help with CDI program development. Practices relying on internal coding professionals or other staff to manage CDI efforts should work incrementally to get started. Whether a practice elects to use an in-house, outsourced, or hybrid CDI solution, these steps should be included in any outpatient CDI program strategy. 

Secure leadership and team buy-in.

Efforts won’t get very far if no one is supporting and reinforcing program adherence. Document time and expenses up-front to avoid surprises. Showcase return on investment potential and specific goals to address known pain points.

Drive the best program approach.

Begin efforts with departments most in need of help. Use real-life examples to show how documentation impacts quality of care and the revenue cycle to garner clinician buy-in. 

Determine key productivity metrics.

Keep specialty-specific considerations as you decide on key performance indicators. Include metrics on known problem areas. Monitor productivity targets and query and physician response rates.

Establish benchmarks and assess performance.

Culling initial benchmarking data is one of the most time-consuming aspects of CDI, but it is also one of the most important for determining focus areas and evaluating progress over time. View performance at both aggregate and individual levels.

Present results and implement a corrective action plan.

Hold regular meetings with CDI, quality and coding team members to discuss program findings. Use tip sheets, presentations and other communications to support training.

When educating clinicians on documentation, start with ICD-10 codes most commonly used in the practice. Review the most frequently required yet overlooked documentation elements. CDI teams should also work with technology departments to make sure that CDI findings are a consideration in EHR optimization. Customize EHR workflows to prompt complete documentation at the point of care.