Clinical documentation is a necessary process for every hospitals’ bottom line. It’s the foundation for payer reimbursement and drives the best patient care outcomes throughout the episode of care. Mistakes in clinical documentation are a real problem for hospitals and have led to millions of dollars in missed revenue. Specifically, before COVID-19, the average 350-bed hospital lost $22 million in revenue capture opportunities. The key area of vulnerability for decreased revenue was shown to be clinical documentation and coding mistakes according to a 2017 HFMA survey.
The source of clinical documentation starts with the physician. The purpose of this work is to document the true clinical picture of the patient stay and can put the hospital at risk if done improperly.
In a 2013 paper, Adele L. Towers, MD, MPH said, “Physicians are not taught how to complete the documentation to accurately assign codes, and physician billing does not require a high degree of specificity…However, the lack of specificity on a hospital record can affect payment. The key is to engage physicians to correlate how clinical documentation provides an opportunity to demonstrate the quality of care that was provided.”
This disconnect between the actual clinical scenario and clinical documentation provided for billing may partly contribute to missing or lost revenue. However, while this is an important aspect for any hospital, for the physician, the most common response to why a physician may feel the effects of burnout is that they are buried in administrative processes and tasks. Physician burnout is a work-related syndrome involving emotional exhaustion, depersonalization and a sense of reduced personal accomplishment. This problem represents a public health crisis with negative impacts on individual physicians, patients and healthcare organizations, and has been widely exacerbated during the pandemic.
According to the AMA, “Physician burnout is costing the U.S. about $4.6 billion annually when you conservatively estimate the costs related to physician turnover and reduced clinical hours.”
To reduce the bureaucratic tasks contributing to burnout, a physician should be educated on clinical documentation to ensure it’s more accurate, compliant and efficient. Improved clinical documentation also will benefit the patient beyond the encounter which prompted it. There is a continuum of care beyond just one hospital for some patients, which requires clear documentation from the prior physician to make future medical decisions for the patient’s health.
Accurate records including recent, as well as distant past medical history, are relevant to current health issues. For example, an NSTEMI can be captured in subsequent admissions if diagnosed within the prior 28 days. Another example is the documentation regarding chronic kidney disease staging. This diagnosis follows the patient and can be involved in combination codes with hypertensive heart disease, both capturable and impactful to future billing even as secondary diagnoses. A more comprehensive chart allows for improved immediate and future patient care.
In reality, the strength of a physician’s clinical documentation not only helps ensure a hospital will be reimbursed for the accurate clinical scenario, but it also will benefit the health of the patient beyond the encounter in which it was made. Physician education in clinical documentation is critical to realizing better health outcomes and hospital performance.
Learn more about Accuity’s customized, data-driven physician education program.