What is a clinical documentation improvement

Case-accompanying coding: How clinics improve their documentation and profitability

Settling treatment cases promptly is still a major challenge for many clinics. Those who optimize the underlying processes can prevent liquidation problems and loss of revenue.

The prerequisite for invoicing hospital treatment is to document and code a treatment case completely and promptly. Both of these contribute significantly to a hospital's liquidity. However, the reality often shows that hospitals have problems completing required documents on time or ensuring the availability of patient records. They also document certain aspects that have an impact on the amount of the billing, partly due to ignorance, not always sufficiently well.

Coding: responsibility rests with the doctor

Inpatient hospital treatment is usually billed as a flat rate per case, which, taking into account the German coding guidelines, results from a combination of ICD-10 codes for illnesses and OPS codes for services provided. The basis for this is the clinical documentation of doctors, nurses or other employees who are involved in the treatment of the patient. The quality and completeness of the documentation are therefore decisive for the quality of the coding and billing.

According to the coding guidelines, the attending physician is fundamentally responsible for listing the diagnoses and procedures. Coding specialists are increasingly taking on this task. Even if a coding specialist finally approves the billing, it is essential that the treating physician finally validates the coded case beforehand.

Documentation: the crux of the matter in patient files

Currently, most clinics code a treatment case after the patient is discharged based on the medical record. In doing so, they refer in particular to the discharge letter and, in the case of operational departments, the surgical report. It becomes problematic when incomplete and incomplete documentation delays timely and proper coding and billing. Despite the requirements of discharge management, clinics often still have problems creating discharge letters on time.

If the clinics sometimes still document in paper form and not digitally in the hospital information system, the availability of documents that have already been created is limited. This is due, for example, to the fact that a finding has not yet been filed in the paper patient file or the file has not yet been forwarded to the coders because it is either still on the ward or, more rarely, is already being digitized. This often also applies to the availability of findings from external service providers such as laboratories, microbiology, and pathology.

Negative liquidity effects arise above all when it is not possible to code and bill a large part of the treatment cases in a timely manner.

Loss of information: there is no exchange within the team

In addition, it becomes difficult if the patient records do not contain all the necessary and revenue-related information. The treatment team is not always aware of which facts play a role in the coding and the amount of the billing and which specific patient documents they have to use for this. This sometimes means that they do not pay sufficient attention to the documentation. This applies, for example, to certain (care-relevant) secondary diagnoses or special services that are eligible for additional payments. In addition, the length of stay is not always medically justified, especially for those patients whose hospital stay is shorter or longer than the resulting flat rate per case defines (so-called short or long stay). Or the main diagnosis, especially in conservative subjects, is not always clear from the doctor's letter. This loss of information occurs especially when the coder and the doctor or the treatment team work independently of one another and have little professional exchange.

Inadequate coordination of the documentation and coding also affects subsequent invoice audits by cost units or the MDK. Often there is then a very complex communication between the coders and treating doctors in order to be able to save the case. If this is not possible, revenues are lost because the cost bearers reduce the bills.

Optimization: case-accompanying coding

There are various approaches to counteract this. The focus is on a regular professional exchange between coders and treating doctors. The medical expertise of the clinicians and the knowledge of the coders with regard to the billing system and coding guidelines should be combined in order to have a positive effect on the quality of documentation, coding and billing.

The following procedure is advisable: In regular coding visits, the team discusses the choice of the main diagnosis, secondary diagnoses and the procedures performed. It also takes into account parameters that are particularly relevant to revenue, such as ventilation hours, services that can be paid for, medication or blood products. At the same time, the team records the ICD-10 and OPS codes directly and carries out the required clinical documentation in a targeted manner. If the patient is discharged, the team can close and settle the treatment case promptly, as it has already done the documentation and coding accompanying the case. The attending physician should finally validate the case. This improved coding can increase the Case Mix Index and thus increase revenue. If the patient is a short or long stay, which can be foreseen by a coding accompanying the case, particular attention must be paid to a corresponding medical justification.

Better documentation quality also has a positive effect on subsequent invoice audits by the cost bearers. An increase in the success rate of tested treatment cases is to be expected. In addition, the time-consuming review process between doctors and coders is likely to be reduced, as they have already clarified critical questions in advance.

Especially against the background of possible revenue losses and liquidation problems, hospitals should pay particular attention to the organization and the processes of their documentation, coding and billing. In doing so, they should also take the respective personnel situation into account. In this context, you should check and use the opportunities that arise from documentation and coding accompanying the case.

Dr. med. Berit Bohnenkamp, ​​MBA

Consultant

Curacon GmbH

Auditing company

81679 Munich