Seven Criteria for High Quality Clinical Documentation

Clinical documentation is the cornerstone for all patient medical records. This information should be of the highest quality to allow for optimal patient outcomes as well as supporting research, medical coding and other uses of the medical record. Its purpose is to adequately relate the patient’s current and historical conditions and treatments with primary focus placed on situations that affect the current medical encounter. It also supports the provider’s defense should the case become a legal issue.

Webinar’s Goals

Review of 7 criteria that all entries in the medical record should include
Impact of documentation on coding & claims
Establishing a CDI team

• Significance of abnormal lab results: querying the provider.
• Measurement of lesions, when taken and inclusion of margins. Why it matters & how reimbursement may be affected.
• Start & stop times & methodology for infusions & discrepancies in billing. Complete reporting for administration and substance.
• Diagnostic testing and medications should be supported in a diagnosis. Unsupported documentation may cost you money.
• Depth of wounds and cause should be clear. Clarity needed for both depth and origin of wound.
• Severity of illness. Hospitals and payers are increasingly scrutinizing patient severity. Lack of detail costs money.
• Diagnosis present on admission? Certain conditions do not generate additional revenue if occurrence after admission.

Areas Covered

The ICD-10 code set requires explicit documentation of conditions & treatments in order to support the severity of patients under treatment as well as allow for the significant specificity required by this code set. Ambiguous documentation and generic coding will no longer guarantee reimbursement and may generate a claims denial for lack of medical necessity. In this session, we will review the theory of high-quality clinical documentation which has the support of healthcare regulatory guidelines and peer-review research.

Additional consideration involves medical outcomes that may result in legal action. When clinical documentation is vague, missing key elements and conflicting statements, the provider may find that he/she is handicapped in supporting medical decisions and patient results, particularly when the result is a negative outcome for the patient.

In today’s healthcare environment, many patients have become educated consumers of medical services. They are more inclined to request their own medical record, carefully review explanation of benefits from payers, and request a review of any information they deem to be incomplete or questionable.

Target Audience

• Coding
• Billing
• Revenue Cycle
• Physicians
• Mid-level providers
• Nurses
• Claims follow-up
• Compliance
• Auditors