Clinical Documentation for Higher Reimbursements

Karen Minich-Pourshadi, for HealthLeaders Media , October 29, 2012

"With the data I'd gathered, I could show the physicians how putting their clinical documentation into a language that coders can understand would affect their outcomes," Oliva says. "With CMS and Healthgrades now tracking physicians' individual performance data, including individual physician mortality rates, seeing this information really hit a nerve."

Once Borgess Health physicians recognized they needed to document that their patients were sicker in order for severity adjustments to apply, it sunk in, Oliva says: "If you don't get the information into the documentation, it doesn't accurately reflect the patient that was treated. And if that physician is compared to another physician that is [documenting accurately], then that doctor's outcomes will look worse. Eventually we'll be paid for outcomes. So I tell them, 'Get the documentation right and you’ll get credit for what you're doing to care for your patients.'"

Physicians were not asked to memorize any codes, just to work more closely with the clinical documentation specialists when more information on the clinical notations was requested. 

"We asked them to be part of the team that’s there to help them get their outcomes to where they should be. Over time, the physicians will learn where they need to put in more information to do a better job documenting," explains Oliva. "This is helping encourage a conversation between the coder and the physician."


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1 comments on "Clinical Documentation for Higher Reimbursements"

Matthew Shafiroff (11/1/2012 at 4:17 PM)
This is an extremely interesting article, especially in the light of the recent CMS accusations of physician upcoding with the use of EMRs. Perhaps articles like this will help shed light upon the fact that big data (from EMRs) allows us to understand where we have been chronically under-documenting for years.




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