Question

Industry professionalsÅueighin thecnallenges and opportunities of marrying clinical and b Il)ng documentationin he foundational objective of any clinical documentation improvement (CD!) program is to produce the most complete and accurate documentation possible. It seems a reasonable goal, yet the industry at large continues to struggle with achieving a balanced documentation product that adequately supports both billing and clinical information needs. Widespread use of EMRs provides an effective way of collecting data, but it also introduces challenges, according to Mark Morsch, vice president of technology with Optum. "While the EMR has provided nqmerous benefits to the health care market, the goal of improved documentation and automated coding derived from that documentation has not yet been fully realized," he says. "One of the biggest challenges is quantity of information vs quality. With electronic records, it is common to have extensive content and data where quantity is trumping quality."In addition, health care organizations can become misguided with their CDI strategies, tilting the scale too far in the direction of optimal reimbursement, says Jon Elion, MD, FACC, president and CEO of ChartWise Medical Systems."Some hospitals got a little excited and found that they could have an opportunity with coaching and creativity to game the system," he says, pointing out that these practices not only result in the potential for negative newspaper headlines but they also do not align with the paradigm shift from fee for service to value and quality.Value-based care and the emergence of multiple reimbursement methodologies exacerbates the problem of increased documentation requirements, Morsch says, increasing physician clamor about problematic EMR workflows and the need to focus more on patient care.

'Rather than causing further physician disruption or requiring physicians to become revenue cycle experts, the common denominator in this equation must be accurate documentation that is reflective of patient acuity, the medical necessity of the care provided, and the quality of care the patient received," he says. "This not only ensures the documentation can support the complexity of the revenue cycle but also provides better communication amongst providers and benefits the most important part of the health system—the patient."While the right equation continues to elude the industry at large, Elion says a proper balance exists. "You are supposed to have the most complete chart you can," he says, pointing to consistent guidance handed down from regulatory and accreditation organizations. The key is finding an equilibrium that addresses all the data needed for billing and reporting, while maintaining the quality of the physician note.

"Accurate documentation supports accurate coding, helping to ensure appropriate payment and accurate quality scoring,' he says, adding that artificial intelligence and natural language processing can provide feedback and corrqctive action at the point of care. "In addition, a proactive approach to ensuring accuracy can reduce costly rework and denials, improve cash flow, and promote information integrity.'

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications, covering everything from corporate and managerial topics to health care and travel.

A. Write a paragraph (6-7 sentences) summarizing the article. Be sure you have
factual information included in your summary.

Answer 1

CLINICAL DOCUMENTATION PROGRAM (CDM): The main aim of this program is to produce clear and accurate documentation in both billing and clinical fields of data collection. Today, the use of EMR (electronic medical record) reduces the burden of data collection but raises challenges based on the field of quantity and quality information. Moreover, healthcare organizations often misguided the availability of EMR with their Clinical documentation Improvement (CDI) programs. It helps to improve the quality of the data in the medical record to better reflect the care patients actually receive. This negative impact happened because of value based care and arrival of reimbursement methodologies. However, it has a positive impact on communication on both providers and benefiters. Finally, accurate documentation supports coding, payment benefits and quality scoring by reducing cost, improve cash flow and promote information integrity.