Provider organizations have always focused on the importance of accurate documentation of health care services, and as an industry we all know that documentation accuracy is key to ensuring the appropriate reimbursement. But as my colleague Dean Farley pointed out in his recent post, the shift to accountable care and new payment models is inevitable. With these new payment models, along with the greater specificity and increased scope for both diagnosis and procedure coding that ICD-10 will bring next year, physicians are going to need to pay even closer attention to care documentation.
An important consideration in the transition to ICD-10 is Clinical Documentation Improvement (CDI), which seeks to improve the quality of provider documentation, helping clinicians better reflect the services rendered and most accurately represent the complete patient encounter. The simplest type of CDI is educating providers about potential documentation weaknesses from both the clinical and financial perspective. While helpful, this is more impactful when coupled with specific examples of deficient documentation. Even so, retrospective analysis and feedback are limited to influencing future behavior and are dependent on follow-on audits to validate changes.
