Better management of clinical documentation processes increases a practice’s bottom line by decreasing the time it takes to get claims paid and reducing claims denials. Strong documentation management makes it easier to create financial stability in a private medical practice and helps streamline revenue cycle management. The best clinical documentation is an integrated approach to patient care that encompasses all office components.
Remember that Everything is Related to Patient Care
According to clinical documentation improvement expert Paul Weygandt, improving documentation procedures brings the best results when patient engagement is encouraged. He says patient involvement can increase revenue impact by up to 6 percent. Patient engagement can be increased by using technology tools to enhance explanations, treatments, and charting. Physicians can reference patient charts during consultations and can even use screens to show lab and other results and offer easy-to-understand explanations to patients.
Use Technology to Increase Efficiency
Make it easy for physicians to capture initial and accurate clinical impressions. Voice recognition software lets physicians and busy clinical staff record notes during or after each patient consultation. Templates in electronic health software ensure that staff includes all necessary information for billing. Offices can integrate mobile devices so physicians can carry records with them through the practice and set up networks so clinical impressions and notes are immediately available for administrative and revenue cycle staff.
Collaborate and Communicate
Cross-department communication isn’t only important in daily documentation management. Building your document management process should be a collaborative endeavor. Billers, coders, office managers, nurses, and physicians should provide input on needs and wants, and the overall system should integrate needs in a way that doesn’t impede the flow of information or claims. Documentation processes should be easy for clinicians but translate readily into coding, claims billing, and backup documentation for claims appeals.
Pay Attention to Data: Measure and Assess
Weygandt says practices must measure the impact and success of revenue cycle processes and tie them back to clinical documentation management where applicable. If claims denials, billing errors, or claim payment delays are tied to documentation, a practice must be able to pinpoint the root cause of the issue and make proactive changes. Regularly assessing documentation procedures lets a practice drive continuous improvement and an ever-increasing bottom line.
Last Updated on February 4, 2014