Wellington, FL -- (SBWIRE) -- 07/26/2012 -- Hospitals and physicians practices must think about a comprehensive clinical documentation review with a view on education. Reimbursement by both the government and private insurers will continue to focus on how care is integrated and how that is reflected in clinical documentation. HSMN’s service helps hospitals and physicians with their clinical documentation practices.

There are several issues to consider in both the hospital and physician practice setting. Does the documentation support the procedure and/or service provided? Is revenue being optimized based on resource use and by being able to document all of the elements for both the hospital and the physician side?

More and more third party payers are auditing both hospital records and physicians’ records to see whether there is consistency in the way the patient is presented in the documentation. There have been findings of inconsistency between documentation and the coder’s understanding of what has taken place during the clinic/physician visit. It is important to return to basics with the Medical staff in the hospital and/or Practice setting.

The next issue will soon be front and center, and that is “Integration of Care”, “Outcomes” and the need for data to support both. Physician practices must re-examine how to comprehensively monitor and manage the quality of patient outcomes. It is east to say: “that will never happen to us”, but the data may say that it already has. In the hospital and clinic setting, clinical documentation is at the very heart of clues that show clinicians focused on the patient problems and integrating their work toward a preferred outcome.

In many physician office practices, patients often speak of their neighbors and relatives who had a “great outcome for their knee surgery last year” or a myriad of other procedures. Practices and Hospitals must consider how they will measure and demonstrate quality. In the hospital and physician settings, the change in coding from ICD-9-CM to ICD-10-CM must be considered.

While it has been postponed, there is no time like the present to do a comprehensive review of clinical documentation to see how the organization or practice will measure up to the new standards and to implement educational endeavors where necessary.

Next Steps:
It has been suggested, and has worked in several settings, to do a Grand Rounds Presentation and discussion of the clinical documentation in actual cases on a prospective basis. Grand Rounds should include a case presentation by a medical staff member or practice member and a clinical documentation representative to critique the presentation and use a “Deconstruction Technique” to parse the elements and reconstruct them in a way that is both accurate and optimized.

Hospital and Physician Practice Clinical Documentation have common elements and clinicians should begin to build a bridge between both with a vision for education.

Health Systems Management Network (HSMN) was founded in 1987 and specializes in providing the following services to hospitals and physician practice groups: clinical documentation and revenue cycle management, comprehensive financial performance improvement programs in both hospitals and practice environments, operational reviews focused on the drivers of the revenue cycle, and organizational assessment and reorganization.