Clinical Documentation Improvement in PACE

Clinical Documentation Improvement in PACE

  • 04 Mar 0
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Capstone LogoClinical Documentation Improvement in PACE

By: Dr. Richard Schamp, CEO

Clinical documentation is at the core of every healthcare encounter. Therefore it should be complete, precise, and reflect the diagnoses as well as the scope of care and services provided.  Assuring consistency in provider documentation that is accurate, specific, legible and timely represents a challenge for many organizations.

Providers (doctors, nurse practitioners, therapists and others) are trained in clinical documentation, but often have developed habits or patterns of documenting that present barriers to ideal documentation.  Clinical Documentation Improvement Plans (CDIPs) describe a collaborative process among providers (and coders, when applicable) to bridge the gap between the data contained in the medical record and what is necessary for complete and proper coding.

Allocating resources to improve clinical documentation is an investment that can produce strong returns. The quality of the documentation is vital to nearly every aspect of health care, and accurate chart documentation and diagnosis reporting determines reimbursement for the PACE organizations under the Risk Adjustment Program.

CMS conducts medical record reviews to validate and ensure the accuracy and integrity of the risk adjustment data submitted by the Medicare Advantage Organization (MAO) and PACE Organization (PO) for payments.   Any MAO organization or PO may be selected for validation. CMS may target, or randomly select, organizations to participate in the medical record review.   CMS validation findings in the past indicate that coded conditions are not supported in approximately 30 percent of the records reviewed.

Risk adjustment data validation (RADV) is the process of verifying that diagnosis codes submitted for payment by the MAOs or POs are supported by medical record documentation for an enrollee. Though POs are small and perhaps less likely to have a RADV audit, every PO should assume that sooner or later CMS will audit its medical records.

Capstone has assisted many PACE organizations across the country in implementing policies and practices specifically designed to assure the providers are documenting and coding accurately the diagnosis codes of their members. These practices include ongoing audits and follow-up training for providers on an annual basis.  Such policies, audits, and training are essential for all POs to demonstrate to CMS and the OIG there is continuous oversight of their providers’ documentation and coding.

Data validation ensures that both the coding and documentation are appropriate.  Upcoding or changing diagnoses to obtain higher reimbursement without supporting source documents is fraudulent. Thoroughly reviewing documentation and coding practices through internal auditing procedures will ensure that data have been reported correctly, and that appropriate reimbursement is received.  A joint effort between the PO, their providers, and coding professionals, is vital to achieve complete and accurate documentation and code assignment.

What specific steps can improve documentation and coding performance?  Here are four steps to start.

Step one: Educate

Currently, PACE Organizations are granted premiums based on their member health conditions and demographic status.  Submitting inaccurate diagnoses that result in an inaccurate HCC category is a compliance risk and could lead to receiving too much or too little revenue.

Explaining the role of clinical documentation and its impact on CMS-HCC to all providers will enable everyone to have a good understanding of the big picture. Important points to make include:

  • Well-documented medical records facilitate communication, coordination, and continuity of care, and promote the efficiency and effectiveness of treatment.
  • Accurate coding is the key to prompt payment, practice profiling, and supports QI processes. It is important for both financial and compliance reasons.
  • Specificity is important for further inquiry into treatment effectiveness for chronic conditions.
  • Showing medical necessity justifies the treatment choice

Step Two: Analyze

Develop a compliance plan, and implement prospective and retrospective, internal and external chart reviews, with ongoing monitoring and feedback. Be sure to review the record based on the official coding guidelines.

There may be opportunities to capture more appropriate CMS-HCC codes.  Many plans use analytics to detect participants who might have missing diagnosis codes based on the analysis of RAPS or other data. Analytics are a good tool but they are not the only way to address the issue of missing diagnosis codes. Even if the analytics identify the patient is missing a diagnosis, and the medical record indicates the patient has the condition, often the doctor has not documented the condition in the appropriate manner (MEAT, etc.) which, from a coding guideline perspective, means that code cannot be submitted.

Step Three: Target

Identifying problem areas is only part of the battle. Translating this knowledge into improved documentation practices produces the real results.

Providers often are overwhelmed with work already, so whenever possible, provide simple solutions and tools to encourage necessary documentation.  For instance, consider templates, when appropriate, that prompt providers to document the status of chronic conditions.  A variety of methods to improve documentation may be tried over time, monitoring their effectiveness and value.

Step Four: Feedback

Ongoing record review and provider education reinforces the essential points of good documentation. Remember: The purpose of the review is to validate whether the medical record documentation supports the codes submitted.  Timeliness of feedback is essential to facilitate a change in behavior.

Finally, keep up the efforts. Provide ongoing, periodic education, including yearly ICD updates, to be sure that your documentation and coding stay on track.


*The information presented herein is for general informational purposes for clinicians only and is not warranted that the information contained herein is complete, accurate or free from defects.