As healthcare has moved away from fee-for-service reimbursement models toward a more value-based system, the idea of using risk adjustment to account for individual patient risk and chronic conditions has become far more important for providers seeking to maximize quality of care.
In today’s healthcare environment, providers are often required to fight simultaneous battles on several fronts. For those pursuing clinical documentation improvement (CDI), they must balance sometimes-conflicting regulatory demands, workflow needs, etc. Further exacerbating the problem is the persistent shift of care provision to the ambulatory setting and the increasing demands it places on provider organizations.
As we have discussed in previous blog posts, outpatient CDI efforts face a number of unique challenges, such as decidedly larger case volumes than most inpatient settings and far shorter clinical visits. These shorter visits produce less usable patient data and offer a condensed window during which multiple team members must work in synchrony—accurately and efficiently—to gather that data. Outpatient providers must also go further, factoring in risk adjustment for each individual in their larger patient populations as well.
Often, problems with risk adjustment appear when inaccurate or incomplete diagnosis coding slips through the documentation workflow. For instance, failure to capture patients’ Hierarchical Condition Categories (HCCs)—and recapture year-over-year—can greatly skew risk scores for individual patients and potentially the overall population. Such mistakes can filter downstream to errors in patient care and increasing claim denials and, potentially, wreak havoc on pay-for-performance reimbursements.
This dynamic puts increased pressure on physicians to capture correct documentation at the point of care—getting it right the first time without a great deal of revision. Many have addressed the issue through Computer Assisted Physician Documentation (CAPD), which provides a number of CDI features. CAPD improves accuracy and lessens physicians’ burdensome workflow by precluding the need to rehash previously captured documentation.
The goal of these products is to allow physicians to complete patient care documentation faster and spend more time with their patients. Unfortunately, many traditional products, which were designed for inpatient settings, lack effective integration of risk adjustment. As a result, many providers are prevented from seeing the most accurate picture of the population they serve—and value-based care programs are not as successful as they could be.