Discussion: Documentation of Diagnosis

Discussion: Documentation of Diagnosis

Discussion: Documentation of Diagnosis

Discuss ways that the documentation of diagnosis, differential diagnoses, and comorbidities affect reimbursement.

            Clinical documentation can be described as the process of collecting patients’ medical data to improve the quality of care provided and maximize claims on reimbursements. Accurate documentation of the patient’s primary diagnosis generated within the EHR and elsewhere in the care facility is greatly associated with maintaining cost efficiency as demonstrated under the value-based reimbursement models (Sanderson & Burns, 2020). Payers rely on accurate clinical documentation to justify the payments made or value-based reimbursement. The justification of value-based reimbursements also relies on appropriate documentation of differential diagnoses and comorbidities, as they affirm the appropriate use of clinical judgment in improving the quality of care provided (Seligson et al., 2021). However, in some cases, healthcare organizations earn incentive payments but fail to justify the achievement to payer from the clinical documentation leading to value-based penalties.

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What are the possible implications of inaccurate documentation for the patient, the health care staff, and reimbursement?

            Inaccurate clinical documentation is associated with several adverse implications for the patient and the healthcare organization from the staff to reimbursements. The patient will end up receiving poor-quality of care, undermining their safety (Hurst & Coopersmith, 2019). Consequently, patients may end up incurring additional medical costs from unnecessary procedures or treatments. With low-quality care, the patient will suffer an increased number of hospital visits and readmission. The healthcare staff on the other hand may also end up making wrong treatment decisions due to inaccurate clinical documentation affecting the quality and services provided (Chapman et al., 2019). The healthcare provider might even end up losing their practice license and face legal charges in case of reported inaccurate clinical documentation. Finally, inaccurate diagnosis can also pose several implications to the healthcare organization in terms of loss of reimbursements, increased morbidity and mortality rates, and inappropriate billing that can result in fraud charges.

References

Chapman, S. M., Oulton, K., Peters, M. J., & Wray, J. (2019). Missed opportunities: incomplete and inaccurate recording of pediatric early warning scores. Archives of Disease in Childhood, 104(12), 1208–1213. https://doi.org/10.1136/archdischild-2018-316248

Hurst, S. D., & Coopersmith, C. M. (2019). Can We Compare Sepsis Outcomes on a Hospital Level If Documentation Is Variable (or Inaccurate)? *. Critical Care Medicine, 47(4), 599–600. https://doi.org/10.1097/ccm.0000000000003599

Sanderson, A. L., & Burns, J. P. (2020). Clinical Documentation for Intensivists. Critical Care Medicine, 48(4), 579–587. https://doi.org/10.1097/ccm.0000000000004200

Seligson, M. T., Lyden, S. P., Caputo, F. J., Kirksey, L., Rowse, J. W., & Smolock, C. J. (2021). Improving Clinical Documentation of Evaluation and Management Care and Patient Acuity Improves Reimbursement as well as Quality Metrics. Journal of Vascular Surgery. https://doi.org/10.1016/j.jvs.2021.06.027

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Discuss ways that the documentation of diagnosis, differential diagnoses, and comorbidities affect reimbursement. What are possible implications of inaccurate documentation for the patient, the health care staff, and reimbursement?