AI-powered solutions must align with applicable coding guidelines

Streamlining the nation’s healthcare system to provide the highest quality of care at a lower cost for patients should be the goal of all healthcare organizations.

While prioritizing this initiative, along with reducing waste and improper payments, much attention has been paid to the role of electronic health record (EHR) clinical documentation and outcomes reporting with respect to compliance. Value-based reimbursement models, reform policies, and even growing consumerism highlight the importance of compliant clinical documentation and coding practices.

We know, for example, that most improper Medicare payments can be attributed to documentation errors, from small mistakes like missing signatures to documentation that only reflects treatment and not the underlying diagnosis. Incomplete documentation means that the Centers for Medicare & Medicaid Services (CMS) cannot determine that the care provided was medically necessary, which leads to inappropriate reimbursements. At the other end of the spectrum, of course, are a small number of cases that overstate patient conditions and level of care, which is not just bad for patient care, but opens up the organization to other risks. Comprehensive documentation that captures accurate disease acuity in the patient population gives clinicians a more detailed picture of patient health to recommend better treatment plans and improve outcomes.

AI-powered Solutions to Managing EHR Clinical Documentation

Artificial intelligence (AI) technologies can support both physicians and clinical documentation improvement (CDI) specialists in their efforts to create comprehensive documentation that’s both accurate and compliant with CMS requirements.

At the point of care, AI-powered, computer-assisted physician documentation (CAPD) solution can augment physicians’ knowledge with evidence-based clinical decision support, helping identify critical undocumented and unspecified details and diagnoses. Specifically, the CAPD solution analyzes patient notes in real time, simultaneously reviewing the entire EHR to assess the patient’s full condition. As the physician builds the documentation, the CAPD interactively prompts the user with evidence-based clarifications that improve the quality of the documentation. When presented with these clarifications and the underlying basis for the recommendations, physicians rely on their own judgment to accept or reject each one; they have the final word.

Likewise, within the CDI workflow, clinically focused programs provide evidence-based clarification guidance and documentation decision support. Solutions bring CDI teams and physicians together in a clinical dialogue about each patient. Team reviews validate that all diagnoses are clinically supported and that coding rules are applied appropriately.

Technology Solutions Must Follow Applicable Laws and Coding Guidelines

Regardless of how clarifications are presented (in person, in physician workflow, or during the CDI process), they must be grounded in the guidelines promulgated by the U.S. Department of Health and Human Services (HHS) and presented in accordance with all legal requirements.

Healthcare organizations must remain vigilant about the technologies they employ to support both documentation and compliance; clinical sources must be sound and coding practices must follow legal guidelines. Furthermore, there can never come a time when technologies replace the people in this process. No matter how far AI advances, the algorithms will always be designed to augment or amplify human intelligence. To be sure, AI will make physicians and CDI professionals more accurate and efficient, but technology can’t replace the human judgment that’s so critical to quality, patient safety, and compliance.

The integrity of clinical documentation affects everything, from patient care to quality scores, and even the ability to provide a defense against denials—and for these reasons, compliance remains at the top of everyone’s priorities list.

A well-designed CDI program coordinated by advanced-practice CDI professionals can serve as the guardrails here, helping manage the various risks involved while supporting accurate and compliant documentation. These safeguards will be the focus of our Part II in our series, coming next Tuesday.

Programming Note:

Listen to Mel Tully report this story live today on Talk Ten Tuesday, 10-10:30 a.m. EDT.


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