Complications in Clinical Documentation Leading to Inaccurate Billing Codes

Clinical documentation is a need that threads through the entire lifecycle of an inpatient treatment episode. The clinical documentation specialist checks the documents of a patient before or within 24 to 28 hours of admission to assess various aspects of the patient’s condition, reviews documents every two to three days, during patient stay, to check their progress, accuracy and assign proper diagnosis related group (DRG). Based on assessment, the clinical documentation specialist also sends feedback to the physician who corrects things if necessary before the documentation is used for preparing reimbursement claims.

As is evident, clinical documentation requires extensive documentation of treatment procedures together with their relationship to be used for preparing reimbursement claims. Seen from a reimbursement claim standpoint, anything that’s not documented doesn’t exist and such are coding complexities that the presence or absence of any fact in documentation affects the choice of code later, making it either accurate or inaccurate. This has become more so since the expected implementation of ICD-10-CM.

ICD-10-CM is much more nuanced than ICD-9-CDM. Whereas ICD-9-CDM included 59 codes for diabetes, ICD-10-CM has more than 200 codes for it. Additionally, for diabetes, ICD-10-CM has added a new provision called ‘poorly controlled’ to the already existing provisions under ICD-9-CDM, controlled and uncontrolled.

Similarly, ICD-10-CM has also increased the number of categories for injuries to cover a larger set of possibilities and arrest the nuances of a wider range of physical specifications of an injury. For example, apart from various details to ascertain the character of an encounter, the ICD-10-CM requires the coder to code the size and depth of an injury. Also, ICD-10-CM contains multiple combination codes to account for relationships between various conditions. After wading through these details, it is not very pleasant to be reminded that the source of these codes is clinical documentation.

Effective clinical documentation requires a grid-like structure underneath the day-to-day healthcare activities involved in an inpatient treatment episode which will arrest medical details, record them and pass them through various phases of the treatment terminating with the discharge of the patient. This process has to be a mix of human effort (to interact with various parties involved) and technology (to record details and facilitate coordination among various specialties – healthcare and otherwise – that interact during the course of a treatment).

MBC’s Revenue Management Consulting can help you with this by performing a thorough analysis of your revenue management cycle and lubricating various points of interaction it has with other areas of operation ensuring smooth flow of data. This involves identifying gaps in your process and addressing them by replacing, if necessary, old software applications with new ones, blocking areas of revenue leakage and identifying areas of staff training., the largest consortium of billers and coders in the US, has helped medical practices improve their finances by its Outsourced Billing and coding services which involve development of accurate electronic billing, intricate procedure coding, electronic filling of claims and a multi-layered application process – collectively resulting in reduced claim denials and enhanced core-business focus.