Over the course of the past year, the Centers for Medicare and Medicaid Services (CMS) along with other government agencies have amended and created certain rules and regulations. These changes serve to highlight the importance of accurate and appropriate clinical documentation and the supporting technologies and processes that capture and report this information. The majority of these changes and measures are designed to help hospitals improve their quality of care, lower their costs and ensure that clinical documentation accurately reflects the acuity of the patients being treated.

We educate our clients to understand that the misstatement of patient conditions in the medical record has ripple effects on the assigned diagnosis codes and DRGs upon which both reimbursement and qualitative scores are based. As such, these misstatements affect reimbursement as well as efficiency and quality measures for both hospitals and individual physicians.

As of 10/1/07 CMS implemented new rules and regulations with respect to the coding and capture of DRGs. These changes require a greater degree of specificity as part of the medical record’s physician documentation in order to obtain the most appropriate reimbursement.

Additionally, beginning in the Fiscal Year 2009, and in accordance with the Deficit Reduction Act of 2005, CMS has introduced an initiative to reduce payments to providers for hospital-acquired conditions (HACs). The effect is a negative payment incentive for complications or infections that were not present on admission and may be the result of substandard quality of care. These conditions are as follows:

CMS views these conditions as indicators of quality and as such will not continue to pay for them at the same rate as they have in the past. CMS has indicated its intent to add to this list through future regulations as well as adding several conditions that have been identified by the National Quality Forum as Serious Reportable Adverse Events (also called ‘Never Events’). These ‘Never Events’ include things such as surgery on a wrong body part or death/disability caused by a medical error.

Lastly, the Department of Health and Human Services (HHS) has announced a long awaited proposed rule. This rule effective 10/1/11, upgrades the current ICD-9 code sets, used to report healthcare diagnoses and procedures in electronic healthcare transactions, to expanded ICD-10 code sets. Although there will be several challenges associated with this new code set implementation, multiple indepedendent studies conclude that the benefits will exceed the costs within a few years. The transition to the new ICD-10 code sets will be multifaceted. Clinicians and coders will require training, processes will need to be updated and systems will have to be upgraded to accommodate the expanded and lengthier code sets.

We work with our clients to ensure their processes and technology can properly support these evolving regulatory requirements

In light of the recent and coming changes that will impact the required specificity of clinical documentation as well as the way in which it will be captured and coded, we have assisted various healthcare provider organizations in identifying ways to improve and hone their clinical documentation review and capture processes. Our experience in working with various healthcare providers indicates that without proper processes and procedures in place many hospitals may not be adequately documenting patient conditions. Both reimbursement and quality can be impacted.

Blum Shapiro Consulting offers several solutions that can help healthcare providers weather regulatory changes. Our proven clinical documentation improvement program, developed jointly with 3M Health Information Systems Consulting, helps to ensure the most appropriate and specific level of physician documentation. Additionally, our solutions and experience with clinical IT implementations and their impact to operations and processes can assist with the eventual migration to ICD-10 code sets. We at Blum Shapiro are prepared to help organizations realize sustainable improvement as we bring our industry experience, specialized operational knowledge, financial expertise and proven project management methodologies to guarantee success.

For additional information please visit:

• American Health Information Management Association
• Center for Medicare and Medicaid Services – ICD -10- PCS
• National Center for Health Statistics
• Center for Medicare and Medicaid Services – Fact Sheets