Managing the work required for your role can be a daunting task. You must observe all of the rules and regulations for work performed and maintain an accurate picture of your clinical documentation to meet the proper reimbursement requirements within your place of service. The key to accurate clinical documentation is smart workflow design. Although many of my columns center around workflow, understanding why particular documentation elements are of critical importance remains paramount. In this column, we will discuss how your documentation creates workflow dependencies, which are vital for your business to be successful within your department. Getting to the details within each dependency is step 1. Understanding why these steps are important is step 2. Applying these steps to your area of business is step 3.
According to the American Health Information Management Association,1
Clinical documentation is at the core of every patient encounter. In order to be meaningful it must be accurate, timely, and reflect the scope of services provided. Successful clinical documentation improvement (CDI) programs facilitate the accurate representation of a patient’s clinical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending. The convergence of clinical, documentation, and coding processes is vital to a healthy revenue cycle, and more important, to a healthy patient. To that end, CDI has a direct impact on patient care by providing information to all members of the care team, as well as those downstream who may be treating the patient at a later date.
In order to capture proper clinical documentation, it is important to configure your workflows with the appropriate elements to meet the rules and regulations of your workplace. One of the first steps is to define your day-to-day structured activities. Understanding each part of your process, no matter how small, is critical. Each action has dependencies within a workflow including the responsibilities of your staff or resources used, rules of governing bodies, and requirements for clinical documentation. The details of each documentation dependency in a workflow are defined by the responsibilities performed by the resources within your place of service. The responsibilities are translated as physical actions or tasks. The actions or tasks form the proper steps for documentation and payment rendered.
In order to define the dependencies within a certain workflow, you need to sit down with your team and discuss the work performed within each discipline. Once the conversation starts, it is imperative to deconstruct the actions taken to complete each task. Each individual task becomes the basis for the actions taken by your team and translated into the clinical documentation for the work you perform.
For example, let’s take the front-end process related to revenue cycle management. Revenue cycle processes include patient registration, compliant billing, and denial management. These processes complement the documentation process for a fiscally successful business. These specific processes are governed by policy, and Medicare is required by the Social Security Act to ensure payment is made only for those medical services that are reasonable and necessary. Policies specify the circumstances under which Medicare covers a given service and most payers have implemented medical necessity guidelines.2 The clinical documentation, diagnosis, and Current Procedural Terminology (CPT) codes* reported must support medical necessity, or the claim will not be paid. Medical necessity guidelines can be payer specific, but most often payers follow the guidelines published by CMS’s National Coverage Determinations or Local Coverage Determinations (LCDs) and related Local Coverage Articles. Also keep your eye on other managed care payer agreements and limitations.
From the time patients call to schedule services, the documentation dependencies begin to configure the start of the revenue cycle workflow. Patient demographic and payer information is gathered, and medical necessity and coverage are confirmed and entered into the documentation system. Each step detailed in these processes is dependent on another.
Another important documentation dependency within the revenue cycle department is obtaining prior authorization for a service to be rendered. According to the CMS,3
Prior authorization is a process through which a request for provisional affirmation of coverage is submitted for review before the service is rendered to a beneficiary and before a claim is submitted for payment. The prior authorization program for certain Hospital Outpatient Department (OPD) Services ensures that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Funds from unnecessary increases in the volume of covered services and improper payments while keeping the medical necessity documentation requirements unchanged for providers. Prior authorization helps to make sure that applicable coverage, payment, and coding requirements are met before services are rendered while ensuring access to and quality of care.
As a workflow dependency, it is important to designate a person who will obtain prior authorization. The steps to investigate the prior authorization of the patient’s coverage necessitate a detailed understanding of the patient’s benefits. An accurate accounting of this work is imperative to support the medical necessity documentation for the encounter and payment rendered. When building your workflows, ensure you have built in the medical necessity language necessary to support the work performed based on the prior authorization obtained.
To further understand documentation workflow dependencies, you should review the Utilization Guidelines found in your LCDs and further details in your Local Coverage Articles. See the Table for an example; you will note that procedures performed have dependencies based on when to perform these procedures, the time frame by which the procedure can be performed, and the number of procedures that can be performed within this time frame.
Review your workflow dependencies from start to finish in your business unit. The workflows ultimately guide your clinical, operational, and financial outcomes. Once you have taken time to determine your dependencies, it is a simple process to optimize results through the workflow created. However, it is your responsibility to continuously review your workflows as dependencies change.
1. American Health Information Management Association. Clinical documentation improvement. 2019. www.ahima.org/topics/cdi
. Last accessed June 22, 2020.
2. Centers for Medicare & Medicaid Services. Fast fact: medical necessity documentation. www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Fast-Facts/Medical-Necessity-Documentation
. Last accessed June 22, 2020.