How clinical documentation helps RCM

'You can’t improve a program until you know where they are.'
By Kevin Fuller
10:08 AM

As they work to bolster their bottom lines, many hospitals have taken a hard look at their clinical documentation strategies. Indeed, putting a documentation improvement program in place can be key to long-term financial stability.

Such programs can directly drive revenue cycle management, said Paul Weygandt, vice president of physician services at J. A. Thomas and Associates, a physician-focused clinical documentation improvement program provider owned by Nuance.

Here he discusses six tips to get your clinical documentation improvement program to boost your hospital’s bottom line.

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[See also: CDI: No longer just about reimbursement ]

  1. Focus on the patient. “Clinical documentation improvement is about enhancing patient care,” said Weygandt. He said when hospitals use clinical documentation as purely a revenue cycle tool, hospitals only see a 2 percent to 4 percent revenue impact, but when hospitals use it as a tool to encourage physician engagement with patients, they see 4 percent to 8 percent revenue impact.
  2. Assess. Hospitals utilizing clinical documentation improvement programs should be performing an objective assessment on quality of documentation and coding on a regular basis. According to Weygandt, hospitals need to understand if deficiencies are due to primary lack of physician documentation, ambiguous documentation, deficiencies in a program or coding interpretation issues. “[You] need to resolve all these issues – you can’t improve a program until you know where they are.”
  3. Break down silos between teams. There tends to be a wall between clinical documentation improvement management teams and coders, physicians and documentation specialists. A program works best, Weygandt said, when those barriers are broken down.
  4. Measure. Hospitals need to get on board with measuring all processes involved in clinical documentation improvement and coding, said Weygandt. “These measurements will let you know how clinical documentation program is performing and identify revenue opportunities,” he said. Everything from physician response rate to clarification rate should be put under the microscope.
  5. Leverage technology. To capture the physician’s actual clinical impression, Weygandt said it is necessary to use appropriate technology, such as templates, which provide an outline, direct text entry or narrative captured through voice recognition.
  6. Use a collaborative approach. A successful clinical documentation improvement program should emphasize collaboration across a health system. Members of the team in different areas of the hospital need to have an understanding of each other’s roles in implementing a program, said Weygandt.
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