As care is increasingly delivered in an outpatient setting, it is critical that clinical documentation improvement (CDI) programs are developed to ensure compensation for care. “Clinical documentation is at the core of every patient encounter,” says the American Health Information Management Association (AHIMA). The association goes on to say that a meaningful documentation process must be accurate, timely and comprehensive of the services provided. The process should also engage physicians so that they begin to associate documentation with a higher quality of care delivery rather than an interference in care delivery.
A recent presentation from the 90th Annual AHIMA conference showcased best practices for ensuring better outpatient CDI in the areas of emergency medicine, wound care and total knee replacement procedures. The presenters outlined these key practical considerations for documentation:
Emergency Room (ER)
Better ER documentation centers around four key questions:
1. Does documentation support the most appropriate visit level?
2. Does documentation support the billable services?
3. Does documentation accurately report staff present for care provided?
4. Does documentation accurately report the amount of time staff spends with critical patients?
When it comes to supporting the most appropriate visit level, what severity is being documented?
● Self-limited or minor
● Low severity
● Moderate severity
● High severity, requires urgent evaluation by the physician but does not pose threat to life or physiologic function
● High severity, poses an immediate significant threat to life or physiologic functions
Supporting documentation is required for all elements of an ER visit, whether that means documenting the need for extra resources to deal with an intoxicated and combative patient, or the documenting the presence of a nurse in the room during a pelvic exam. The timeframe of patient time with nurses is a key element in being able to bill for critical care, with a requirement that at least 30 minutes of critical care services are provided and documented.
Wound Care
When it comes to wound care delivered in an outpatient setting, it is important to have clear and consistent documentation. Here are the key elements needed in the documentation:
● Describe the type of wound, location, and size
● Describe if the wound is a partial or full thickness wound
● Describe stages of pressure ulcers
● Describe depth of pressure ulcers
● Any undermining/tunneling/sinus tract
● Drainage, type, amount or odor
● Various types of tissue in the wound bed
● Wound edges and surrounding tissue
● Indicators of infection and pain
● Document interventions for healing and conditions that would affect healing
● Current topical treatment plan, response to treatment, modifications to plan, implementations of new orders, reasons for not changing treatment plan, referrals
● Document any education given to patient and caregiver
Total Knee Replacement
With total knee replacement procedures, it is important to note in the documentation that the procedure is appropriately offered in an outpatient setting. In order for the procedure to be taken off of the inpatient-only (IPO) list, it must meet the following criteria, all of which should be documented:
● A low anesthesia risk
● Few or no comorbidities
● Family at home to support
● A patient can tolerate rehab in an outpatient facility or at home
● Physician expects the patient to need fewer than two nights of hospital care
For more information, contact Saince about PracticePerfect, a platform to help you address outpatient and ER CDI.
