Quality Documentation Improvement
Today’s health care organizations struggle to continue providing quality clinical care in the face of increasing operating costs and declining reimbursement. The Medicare Recovery Audit Contractor program and The Center for Medicare & Medicaid Services’ move to severity-adjusted DRG methodology bring additional challenges.
Many organizations respond to these challenges with short-term fixes, but surviving in today’s tight health care market demands long-term solutions — including improving clinical documentation practices to ensure that your organization receives appropriate reimbursement. Missing, incomplete or inaccurate documentation can result in compliance and continuity of care issues, denied claims, inadequate reimbursements, and inaccurate perceptions of the quality of care your organization provides.
VHA’s team of documentation experts will work with your staff to develop a custom, step-by-step process to implement and sustain improvements in your organization’s documentation practices. We’ll help you assess your current documentation, implement new processes, educate physicians, coders and documentation specialists, and ongoing monitoring.
VHA’s Quality Documentation Improvement services can educate your employees on the elements of documentation necessary to capture the technical requirements that will ensure accurate reimbursement while also documenting the clinical picture for accurate profiling of severity of illness.
Solution
Implementing and sustaining improvements in documentation practices requires a focused, sustained effort, including an assessment of current documentation; education for physicians, coders and documentation specialists; and ongoing monitoring and education.
VHA’s Quality Documentation Improvement services can help your organization initiate a long-term, comprehensive plan for improvement or help improve your current documentation program. Our seasoned clinicians typically bring more than 15 years of health care experience to successfully address your challenges — and they have the track record to prove it.
Our Services
VHA’s all-encompassing clinical quality documentation improvement services are designed not only to determine areas for documentation improvement, but to put in place more efficient processes to ensure more accurate documentation in the future.
Our experts begin by reviewing an appropriate sampling of patient records for documentation improvement opportunities and interviewing key hospital personnel to gain an understanding of the organization’s current documentation processes. We will perform a case mix analysis and assist with your coding staff to increase their understanding of coding guidelines, documentation requirements and efficient compliance practices.
VHA will also work with key stakeholders to develop a detailed, customized plan to implement improved documentation practices - putting your organization on the road to achieving a more appropriate level of reimbursement. Also critical to reaching your documentation improvement goals is ensuring that everyone involved in the process, including coders, documentation specialists and physicians, have a thorough understanding of what it takes to truly achieve improved documentation — and what their role will be in helping your organization reach your documentation goals.
VHA offers a variety of training and education methods to connect with the intended audiences and translate vital lessons into integrated daily practices, including classroom sessions, small-group training and real-time practice sessions. Classroom sessions for documentation specialists and coders cover DRG documentation algorithms, coding clinic references and compliance requirements. Afternoon practice sessions allow participants to apply what they’ve learned to daily practice, including completing medical record assessments and concurrent physician query forms and posing questions to physicians. VHA’s Performance Tracking and Monitoring Application is an integral part of ensuring your organization’s ongoing documentation success. Our proprietary application tracks and reports:
- Documentation specialist productivity, including the number of cases, physician queries and physician responses
- Initial and final DRG, relative weight, and reimbursement
- Number, type and response rate of queries by individual physician
- Program impact, including case mix index and revenue
Our seasoned documentation experts will also conduct post–implementation follow-up visits to answer questions, reinforce objectives and ensure your organization’s ongoing success.
Benefits of VHA’s Quality Documentation Improvement Services
As a result of your clinical quality documentation solution, your organization can expect to achieve:
- Improved hospital and physician profiles
- Increased teamwork between hospital and medical staff
- Greater compliance with Office of Inspector General, Medicare and Joint Commission documentation requirements
- More appropriate reimbursements for the hospital and physicians
- Fewer accounts receivable days due to fewer post-discharge questions to physicians
- Accurate reflection of severity of illness and a more appropriate case mix index
- Ensured long-term success of your QDI program through continued education and monitoring
Contact Us
For more information, please contact VHA Customer Service at (800) 842-5146 or vhacustomerservice@vha.com.
