Finding themselves at the center of a tumultuous, dynamic healthcare environment, physicians are becoming increasingly frustrated and anxious, frequently questioning their career choice. Preparation to be a lifelong healthcare provider inadequately prepares clinicians for the emerging value-based healthcare world to which they are being subjected. Physicians believe that they have little control over or input into the metrics that are rapidly determining their fates with healthcare organizations, third-party payers, and inevitably patients themselves.
It's been two years since the American Health Information Management Association (AHIMA) joined ACDIS to offer the industry physician query instructions in Guidelines for Achieving a Compliant Query Practice, published in February 2013.
Ensuring detailed documentation isn't important only with respect to documenting medical necessity. Case managers should also ensure physicians are including enough information in patient records to help them accurately estimate length of stay (LOS), says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, CCDS, an independent health information management consultant in Madison, Wis.
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician documentation to accommodate the new code set was a top concern for the healthcare industry.
Chasing down information on incomplete records can be overwhelming and a lost cause. What do you do when a medical record is incomplete 30 days after discharge (or 14 in California's case) and thus does not meet regulatory standards? Do you file it away without an answer to an open query or a signature from the practitioner? What if the responsible practitioner retired, expired, or is no longer practicing at your facility? Are you doing everything you can to get most deficiencies completed prior to the patient being discharged?
It's been two years since the American Health Information Management Association joined ACDIS to offer the industry physician query instructions in Guidelines for Achieving a Compliant Query Practice, published in February 2013.
Since the implementation of the Hospital Value-Based Purchasing (HVBP) Program in 2013, CMS has adjusted the MS-DRG payment for each traditional Medicare discharge. The type and amount of the adjustment, which could be a financial penalty and/or an incentive payment, is determined by the hospital's performance for defined quality measures, such as risk-adjusted mortality. Since that time, the number of pay for performance (P4P) programs and quality measures has expanded. By 2017, P4P payment adjustments will impact up to 6% of traditional Medicare revenue.
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician documentation to accommodate the new code set was a top concern for the healthcare industry.
The ICD-10 implementation deadline is just around the corner, so hospitals must carefully assess their systems and processes to ensure things go smoothly on and after October 1.
The road to ICD-10 has been a long one, and we still have many miles ahead of us. Organizations have invested a significant amount of time and money into this venture, and even though October 1 is rapidly approaching, there’s still work to be done before and after implementation.
