A health care organization's compliance efforts, treatment plans, outcomes, and financial success depend on solid clinical documentation. A comprehensive, accurate, and timely clinical record ensures that patients are receiving the best care possible and that all providers have a complete picture of their patients’ health.
A detailed medical record is also essential for accurate coding. Increasingly, government payers like Medicare and Medicaid are requiring specific documentation before issuing payments and reimbursements. Likewise, private payers have increased their administrative oversight through complex pre-approval processes and also require very specific documentation criteria for reimbursement.
Learn how to enhance record-keeping through a process known as clinical documentation improvement, plus discover the digital tools that can help behavioral health and human services organizations achieve this.
Understanding Clinical Document Improvement
There’s an increasing demand for health care providers to meticulously document clinical encounters in patient health records. In fact, a 2020 study found that clinicians spend over 16 minutes documenting a single patient encounter. Administrative tasks such as reviewing documentation, completing treatment notes, and entering orders are time-consuming and leave less time for interacting with the patient.
Boilerplate solutions, like billing checklists, fall short as health care moves to value-based care measures. Clinical documentation improvement pinpoints deficiencies and streamlines processes. As such, CDI supports a provider’s ability to capture clinical care accurately, comply with coding requirements, and contribute to an organization’s financial goals without compromising meaningful interactions with patients.
CDI aims to produce more clinically relevant documentation that does away with redundancy and focuses on improving patient outcomes. However, implementing CDI programs can be daunting. It’s important to convey the benefits of a CDI program, have a plan in place, and use digital tools such as a comprehensive electronic health record (EHR) system to support meaningful clinical documentation improvement efforts.
Benefits of Clinical Documentation Improvement Programs
Acccurately recording and tracking patients' health information is beneficial not only for patients but also for billing companies and health care practitioners. CDI programs ensure that patients, providers, and payers are on the same page when it comes to communicating and providing the appropriate care. Here’s a closer look at some CDI benefits.
Improves Patient Outcomes
Unfortunately, errors in charting are quite common. The most frequent issues are medication list errors that may include inaccurate medications, dosages, and frequencies. Inaccurate medical histories or missing allergy information are also common errors. When diagnostic tests are inaccurately recorded, patients may not get the right treatments. However, when clinicians produce accurate documentation there are fewer medical errors and patient outcomes improve.
Facilitates a Trusting Relationship
Mistakes in clinical documentation can cause misunderstandings between patients and providers. An inaccurate accounting of a patient's financial obligations can result in erroneous charges. Patients' relationships with providers can be damaged when they receive incorrect treatment or are asked to pay more than they owe.
Shortens the Revenue Cycle
Accurate clinical documentation reduces denials. When patient care is thoroughly documented, payers have the appropriate information needed to streamline approvals, which leads to a shortened revenue cycle.
Meets Ethical Standards
To meet ethical obligations, clinical documentation improvement programs must be compliant with regulatory standards. For example, the first standard is to ensure that the medical record is confidential, accurate, complete, and consistent in order to demonstrate quality measures, as well as to facilitate coding and reporting of high-quality health care data.
Documentation practices that violate federal and state statutes, regulations, and official rules and guidelines are not supported by ethical programs. A good CDI program avoids unethical practices such as unlawfully increasing payment, improperly qualifying someone for insurance coverage, avoiding quality reporting, or skewing data.
3 Steps to a Value-Based CDI Program for Behavioral Health
Documentation is key to compliance and reimbursement across the health care continuum. CDI programs are integral to providing high-quality health care and ensuring better patient outcomes. Building a quality documentation improvement program begins with program design, choosing a certified team, and fine-tuning the process.
Step 1: Analysis
In order to meet value-based care criteria, clinical documentation must be examined. Compliance issues such as lack of timely documentation of patient orders, assessment tracking, admission screening, patient comfort measures, and medication administration become more apparent when clinical documentation has been analyzed. Clinical documentation improvement programs should look for ways to streamline clinical workflows in order to decrease the time spent on documentation and improve productivity and efficiency.
Step 2: Team-Building
Clinically integrated value-based care is becoming an essential part of behavioral health. This means including multiple disciplines in patient care. As a result, clinical documentation becomes more complex. It takes a unique skill set to know which documents to include in the patient record.
A clinical documentation improvement team should include credentialed CDI professionals trained in all aspects of patient records, medical coding, Medicare and Medicaid services – including Medicare Severity Diagnosis Related Groups (MS-DRGs), heath care revenue, and credentialing.
Certified Coding Specialists (CCSs) are American Health Information Management Association (AHIMA) certified. AHIMA training focuses on relevance, reliability, and data quality as well as coding proficiency. Clinicians or medical coders can pursue certification and training to learn the best methods for classifying medical data from patient records.
Clinical Documentation Integrity Specialists or CDI Specialists are clinicians who manage, assess, and review medical records to ensure that all information accurately reflects the patient's severity of illness and clinical treatment.
Certified Clinical Documentation Improvement Specialists or Certified Clinical Documentation Improvement Practitioners demonstrate expertise in clinical documentation within patient health records. CDIS practitioners often teach the Certified Clinical Documentation Specialist (CCDS) courses, CDI boot camps, and webinars.
Step 3: Evaluation and Fine-Tuning
Evaluate how well your program improves clinical documentation for compliance purposes as well as for treatment planning and outcomes for value-based measures. Fine-tune your program to streamline workflows so that the entire documentation process is easier and more intuitive for providers. You may also want to consider implementing an interoperable EHR system.
Unified EHRs Support Clinical Documentation Improvement
By using electronic health records, clinical documentation practices can be improved to meet regulatory requirements more completely. As a result, clinical documentation becomes a more efficient practice for caregivers and enhances the quality and safety of care for patients. ContinuumCloud’s comprehensive EHR solution can support your clinical documentation improvement program by providing the following features.
Interoperability: EHR interoperability enables doctors to provide care coordination for their patients by helping transmit and move clinical documentation between hospitals, medical centers, or other care facilities more easily.
Electronic prescribing tools: E-prescribing software tools allow providers to electronically generate and transmit a prescription order directly from the heath care system.
Clinical decision support (CDS): CDS consists of providing clinicians, staff, patients, or others with knowledge and tailored information, which is intelligently filtered or presented at the right time to enhance health and health care decisions.
Improved workflows: EHRs play a significant role in improving clinical documentation workflow, such as coding a patient's clinical status. By optimizing the use of EHRs, providers can improve the quality of patient care and improve the efficiency of the system.
Make ContinuumCloud’s EHR Part of Your Clinical Documentation Improvement Process
Clinical documentation improvement can contribute to behavioral health's increased focus on delivering value-based care. Accurate, confidential, and complete patient records contribute to patient safety and better patient outcomes. In addition to program design and credentialing, you’ll need the latest digital tools.
With ContinuumCloud’s comprehensive EHR solution, you can streamline clinical documentation workflows, provide clinical decision support, use e-prescribing technology, and support interoperability to deliver a higher quality of care.
To get started designing a clinical documentation improvement plan that works for your behavioral health organization, connect with us today.