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Clinical Documentation and Coding: The Foundation of Healthcare

Healthcare quality and data come from clinical documentation.

Bricks and mortar are the foundation of many a structure. Clinical documentation and coding are similar, as they are also the supportive building blocks in healthcare and can be thought of as foundational as well. In healthcare, over the past 25-30 years we’ve seen the use, need, and importance of clinical documentation and coding greatly increase. It doesn’t matter if it’s for diagnoses or procedures, inpatient or outpatient, or private, public, or government payers – the importance is still there.

One of the historic factors to this increased importance has been reimbursement methodologies, as they are driven by the coding, which is directly linked to the clinical documentation. With the connection to reimbursement comes attention to accuracy and compliance, which really goes hand in hand with all clinical documentation and coding activities and functions.

We have also seen more emphasis on healthcare research, which also has a significant dependence upon clinical documentation and coding. Research studies involve a vast array of information, including social factors, financing systems, organizational structures and processes, health technologies, clinical data, and personal behaviors, all of which is encapsulated in the form of data – some of which comes from the documentation and coding.

Healthcare quality and data are gaining more and more importance as well, and key elements include coded data, which comes from the clinical documentation. We see the landscape shifting more towards quality metrics, but those metrics are often associated with documentation and coding accuracy and integrity. According to the Institute of Medicine (IOM), there are six domains of health quality:

  1. Safe: Avoiding harm to patients from the care that is intended to help them.
  2. Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively).
  3. Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
  4. Timely: Reducing waits and sometimes harmful delays for both those who receive and give care.
  5. Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.
  6. Equitable: Providing care that does not vary in quality among groups of those with varying personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

One can see that these domains are supported by data and information, much of which is obtained from clinical documentation and coding. Thus, as we continue to strive for quality in healthcare, let’s keep these factors in the forefront in relation to our clinical documentation and coding activities and functions.

It’s not always simple or easy, however, to obtain or understand clinical documentation and coding. There are complexities to both, and to the rules that must be followed. Certainly there are some important resources to utilize in your efforts starting today. I like to use the following, to start:

  • 2018 Official Coding and Reporting Guidelines
  • American Hospital Association (AHA) Coding Clinic on ICD-10-CM/PCS
  • AHA Coding Clinic on HCPCS
  • American Health Information Management Association (AHIMA) Standards of Ethical Coding
  • AHIMA Ethical Standards of Clinical Documentation Improvement
  • AHIMA Practice Brief: Guidelines for Achieving an Effective Query Practice
  • 2016 AHIMA Clinical Documentation Improvement Toolkit
  • AMA (American Medical Association) CPT Assistant
  • Association of Clinical Documentation Improvement Specialists (ACDIS) Code of Ethics
  • Office of Inspector General (OIG) Compliance Program Guidance
  • OIG Measuring Compliance Program Effectiveness: Resource Guide

Even with the above key resource tools, we still have pressure to achieve and obtain more and more. Thus, healthcare compliance should also be included in this list of important tools when it comes to clinical documentation and coding.

Compliant clinical documentation and coding is essential to every healthcare setting, no matter the individual responsible for and/or performing the tasks. We need to ensure medical necessity is being met, of course, but not to a fault, whereby we are utilizing diagnoses only to obtain the coverage and medical necessity acceptation. We shouldn’t be making or using the EHR (electronic health record) or other technology to lead physicians to a particular diagnosis on the screen or use technology to game the reimbursement system(s). We shouldn’t single out a payer in an effort to improve the specifics of the clinical documentation, nor intimidate or lead the provider to reimbursement-only diagnoses or procedures. There are many do’s and don’ts when it comes to clinical documentation and coding that must be followed in order to ensure the healthcare foundation is strong and accurate.

What will the next generation of clinical documentation and coding look like, and how will it be achieved? Those questions are ones we all should be thinking about and trying to find answers for. Certainly, compliant technology will remain a part of innovation and solutions in the future. We see advantages to using the electronic health record that can be leveraged to improve clinical documentation, and ultimately coding; just the mere fact that documentation is electronic and not written is a huge benefit to the healthcare system as a whole. Any foundation needs to be strong in order to last.

In the meantime, we must be diligent in our awareness efforts, engagement, education, compliance, auditing, and monitoring of clinical documentation and coding so that it is accurate, complete, and ethical. The ethical standards of coding professionals and clinical documentation improvement specialists should not be forgotten and always adhered to, for they provide the foundational guidance and rules of the industry.

Our efforts need to focus on clinical documentation and coding to ensure that it is a true reflection of the patient care that was provided – not simply the correct words or codes that “pay.” We must not lose sight of the broad impact that clinical documentation and coding have on healthcare and avoid neglecting the ethical responsibility we have for the foundation of support we are building and maintaining.

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Gloryanne Bryant, RHIA, CDIP, CCS, CCDS

Gloryanne is an HIM coding professional and leader with more than 40 years of experience. She has an RHIA, CDIP, CCS, and a CCDS. For the past six years she has been a regular speaker and contributing author for ICD10monitor and Talk Ten Tuesdays. She has conducted numerous educational programs on ICD-10-CM/PCS and CPT coding and continues to do so. Ms. Bryant continues to advocate for compliant clinical documentation and data quality. She is passionate about helping healthcare have accurate and reliable coded data.

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