Health Information Management

Communicate link between quality of physician documentation, quality of care

HIM-HIPAA Insider, July 21, 2014

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Healthcare is increasingly moving from a quantity-based system to a quality-based one. A quick glance at the 2015 IPPS proposed rule and its quality focus proves the point. Physician documentation drives those quality measures. If the physician fails to document a condition is present on admission, the condition may end up being coded as a HAC. That could negatively impact hospital quality scores and reimbursement.

The quality of care provided at a facility reflects the quality of the documentation and coding, says James Fee, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, associate director of Huff DRG Review Services in Eads, Tennessee.
One problem, however, is that physicians were never taught how to communicate with coders. They are taught in medical school and residency that the purpose of the medical record is to communicate with their colleagues, Fee says. "That explains why the volume overload, pulmonary edema, the nondescript terms are written there, because a clinician will look at that and say, the patient has heart failure."
Physicians also don't know that their documentation is used as the basis for clinical grades and performance measures, Fee says. "Physicians don't understand what happens after the patient leaves the hospital." The physician's documentation is the data he or she can control.
Physicians being graded without knowing how to study for the test, Fee says. Give physicians tools, such as tip sheets and EHR prompts, to help them.
But without the documentation, coders can't tell the story of the patient and give the physician credit for what he or she did, Fee adds. Physicians also don't always understand the importance of documentation for core measures. All of the core measure ratios are defined by the severity of risk the patient brings to the table, Fee says. That's the story the documentation should be telling, but physicians don't know that.
Continue reading "Communicate link between quality of physician documentation, quality of care" on the HCPro website. Subscribers to Briefings on Coding Compliance Strategies have free access to this article in the July issue.

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