Q&A with Donald M. Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and keynote speaker at the upcoming 2013 HFMA National Institute, recently caught my attention. As hospitals look for new approaches to ensuring quality patient care and the financial integrity of their institutions, they’re increasingly becoming focused on creating healthcare systems that embody the attributes that Berwick points to in this piece: “seamless, coordinated, patient-centered, (and) free of waste.”

In order to make the massive changes involved in the transition to value-based healthcare, providers must look for new ways to balance patient care and the business of healthcare appropriately. One way providers are doing just that is by looking for incremental ways to improve care coordination while also increasing margins beyond the atypical “full-bed” scenario that Berwick also points to in his piece.

A simple way to embrace this emerging approach to care involves changing to a concurrent format for the discharge summary. Who wants to wait for a discharge summary that is often not ready at the time of coding, missing needed documentation, or failing to support inpatient diagnoses? Often, hospitals will choose to code the encounter prior to receiving the complete medical record. However, hospitals do so at their own risk. Recovery Auditors (RACs) review the entire medical record when performing diagnosis-related group (DRG) validation. If a hospital codes without the full discharge summary, this may increase their chance of error, and RACs will not take this into consideration. Furthermore, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requires that discharge information be documented or dictated and authenticated within 30 days post-discharge, and such information must be compiled on patients with lengths of stay greater than 48 hours.

Implement a Concurrent Approach to the Discharge Summary

The solution to the incomplete discharge summary is to create a concurrent care summary during patients’ stays. Having a concurrent care summary is not only about faster billing, but it helps communicate vital information about a patient’s care plan to the post-hospital care team. In addition to improved care transitions and patient safety improvements, a concurrent care summary leads to timely and accurate discharge summaries, which are important for the following:

  • Successful Accountable Care Organizations (ACOs)
  • Better documentation for improved population health management
  • Accurate, timely and updated problem lists
  • Defending against RAC and payor denials
  • Appropriate reimbursement for severity
  • Discharge summary dictation
  • Improved clinical documentation, compliance, documentation consistency, and precision

Documentation Specialists and the Care Summary

With clinical documentation specialists (CDSs) already focused on concurrent documentation, giving them responsibility for the care summaries and problem lists has become a natural progression in their roles and responsibilities. With careful oversight by a CDS, a care summary becomes the trigger for a timely and accurate discharge summary.

For example, clinical documentation improvement (CDI) practitioners at Allegheny General Hospital in Pittsburgh provide care summaries to their hospitalists. The care summary provides a detailed composite of the patient’s clinical case and includes a reason for admission, a confirmed and ruled-out problem list, and clinical support for diagnoses. The CDS uses documentation in the medical record to craft the care summary, capturing all “impressions, assessments, and plan-of-care” as documented by the physician or provider.

As a result, the care summary has become a vital tool used by physicians as they finalize the discharge summary. Due to the success and recognition of this approach, other physician specialties now also are requesting care summaries.

When working with advanced clinical documentation programs, the CDS automatically is prompted to note impressions, corresponding findings, and treatment for individual dates. After the CDS has entered the principle diagnosis and secondary diagnosis codes, the care summary will capture subsequent confirmed diagnosis codes as they occur, along with supportive documentation. The goal is to balance appropriate details with concise summaries. At a minimum, impressions, findings and treatment should be recorded for all dates that add or confirm diagnoses. Of course, final coding remains the domain of professional coders.

As providers transition to value-based healthcare, they must remember that small changes often can have big impacts on both patient care and financial integrity. As such, healthcare organizations should make care summaries an important part of their CDI programs moving forward.

If the discharge summary does not support documentation in the medical record, you find yourself with more than your fair share of frustration.

The bottom line is this: Make sure your summary and medical record tell the same story.

About the Author

Melinda Tully, MSN, CCDS, CDIP, senior vice president of clinical services and education for J.A. Thomas & Associates (a Nuance Company), has played a critical role in the development and expansion of advanced clinical documentation improvement (CDI) programs for the last 14 years. She is a nationally certified clinical documentation specialist through the Association of Clinical Documentation Specialists (ACDIS) and is nationally certified by the American Health Information Management Association (AHIMA) as a documentation improvement practitioner.

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