Without accurate, complete, and timely documentation, none of the work that behavioral health practitioners do would be possible. Clinical documentation in an electronic health record includes detailed explanations of a patient’s illness, examinations, tests, treatments, and health outcomes in the past and in the present.
Two of the greatest benefits of an electronic health record (EHR) are that it provides a chronological record of patient health and contributes to high quality of care. When care information is documented in a patient’s EHR, that facilitates a number of health care processes, including:
- Evaluation and planning of the patient's immediate treatment, as well as monitoring their health care over time, by the physician and other health care professionals
- Continuity of care and communication between doctors and the rest of the care team
- Review and payment of claims in a timely and accurate manner
- Allowing for utilization review and quality evaluations
- Providing data that can be collected for research
How Clinical Documentation Impacts Revenue Cycle Management
Clinical documentation affects many aspects of the revenue cycle. Regardless of how talented your medical coders are, if your clinical documentation is incomplete, the wrong code may be assigned. Billions of dollars are lost each year due to denials of health care claims.
Additionally, errors in clinical documentation can lead to misunderstandings between patients and providers. Whether it's an inaccuracy from a form the patient fills out at the beginning of their visit or an incorrect bill they receive afterward, erroneous documentation can result in a patient receiving improper treatment or paying more — and may ultimately compromise the patient’s relationship with their provider.
Behavioral health as an industry may seem stuck in a fee-for-service model, with the switch to value-based payments lagging behind other specialties. However, when you consider how the value-based reimbursement model links data quality to cost efficiency, accurate clinical documentation and coding will be increasingly crucial for payers to justify paying the full value-based amounts. Furthermore, inaccurate notes can result in penalties if clinical documentation fails to prove to payers that health care organizations earned an incentive payment.
Clinical Documentation in Behavioral Health
In behavioral health, clinical documentation is often used as a means of communication between professionals. When records aren't properly documented with relevant facts noted, it can prevent the next practitioner from delivering appropriate care to a patient. When communication fails, there are often unintended complications. According to research, communication failures commonly lead to serious medical errors, including sentinel events.
Complying with federal and state laws is another reason to keep track of the behavioral health services you provide. The law dictates that behavioral health providers maintain records that show the extent of services, care, and any supplies provided. This includes creating supporting documentation when necessary. In the event that a behavioral health practitioner's treatment is challenged, proper clinical documentation can help them avoid civil, criminal, and administrative fines.
Clinical Documentation Requirements for Reimbursement with Medicaid
For Medicaid claims, behavioral health documentation requirements are very specific and must be followed to avoid denied claims. Medicaid services criteria require behavioral health providers to include the following clinical documentation elements:
- Reflect on the medical necessity of the patient’s treatment and justify the clinical rationale in accordance with state law.
- Document the active treatment in accordance with state law.
- Include documentation of all face-to-face time spent with the patient in a complete and accurate evaluation.
- Be sure documentation is legible.
- Sign and date clinical documentation.
- Be sure that billing and coding are correct.
What Is Clinical Documentation Improvement?
Clinical documentation improvement refers to the implementation of programs and processes aimed at improving the documentation of clinical notes and records. The best way to enhance your behavioral health system’s electronic clinical documentation is to implement a practice management system software program that offers the following features:
Electronic Health Records
An intuitive, easy-to-use electronic health record system is integral to good practice management software. Cloud-based EHR systems enable authorized users to access all uploaded data from anywhere and at any time. The use of EHRs allows practitioners to store their documentation in a more consistent manner and ensures they always have access since all clinical notes, files, and records are stored in an electronic database.
Practice Management System
Maintaining good documentation and writing clinical notes are comprehensive tasks that can be both time-consuming and overwhelming. The use of practice management software streamlines these processes and reduces the time practitioners spend catching up on notes. The key to maintaining a successful business is optimizing efficiency, and practice management systems can help you save time that can be spent on other, more critical tasks.
Mobile Access
Most practitioners and patients use mobile devices. It has become increasingly important to be able to complete certain health care tasks remotely — a process made possible by practice management software. In programs with this feature, practitioners can complete patient records and clinical notes and store these electronically using just their mobile device, helping them stay organized regardless of where they are.
Auditing for Clinical Documentation Integrity
According to the American Health Information Management Association (AHIMA), coding audits are becoming more important to achieve clinical documentation integrity. A coding audit is either an internal or external process that evaluates targeted medical records and bills for accuracy.
EHR audits are crucial for confirming that the level of service reported matches the level of documentation provided, that all reimbursement requirements are met and that only authorized individuals are accessing or entering information into patient records.
A detailed audit trail includes the name of the user (clinician, coder, care team member, etc.); the application or workflow triggering the audit; the workstation; the document being audited; a description of the event being audited; the clinical documentation specialist running the audit; and the date and time. In order to perform compliance audits, you need to be able to capture what documentation was amended, such as coded data or health data, and also determine if there have been any deletions in the health record.
EHRs should include audit trail functionality to boost the integrity of health record documentation. Lack of audit trails may lead to legal liability for the organization by inadvertently protecting criminal activity. In addition, without an audit trail, it may be impossible to determine if and when documentation was corrected or amended, who made the changes, or what they were. Audit trail functionality can help detect unintentional errors, as well as instances where an alteration of records was intended to prevent the discovery of damaging information.
Choose ContinuumCloud for Clinical Documentation Excellence
Clinical documentation is used for creating cogent electronic medical records in health care and behavioral health to support decision-making in both inpatient and outpatient settings. Clinical documentation is also useful in facilitating communication between clinicians at health care facilities. Finally, it serves as the basis for medical coding, which directly impacts patient care and the revenue cycle.
Electronic documentation tools offered by ContinuumCloud enhance communication between behavioral health providers. They include features designed to improve both the quality and utility of clinical documentation.
ContinuumCloud’s EHR with integrated revenue cycle management technology was intentionally designed for the behavioral health care industry. Our system produces clear clinical documentation that results in quality reporting and ensures that behavioral health care organizations can improve their revenue cycle management.
With ContinuumCloud, clinical documentation, revenue cycle management, required reporting, and administrative tasks become easier and more efficient. To learn more about how our EHR system can improve your clinical documentation and make a positive impact on your revenue cycle management, connect with one of our experts today.
