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Mobile App Helps Providers Better Document Conditions and Care

Reimbursement coding revisions demand improved record-keeping, researcher says (Dec. 17)

One of the key features of healthcare reform is the linking of outcomes with reimbursement — a development that places even greater importance on the thoroughness and accuracy of documenting a patient’s condition and care. A new suite of tools, including a mobile app for iPhones and iPads, developed by the University of Rochester Medical Center (URMC) may help healthcare providers paint a more precise picture of the health condition of the patients they treat.

“The Centers for Medicare and Medicaid Services (CMS) has adopted significant coding revisions for reimbursement,” said Yousaf Ali, MD. “They marked a substantial step forward, paying close attention to other serious conditions that sometimes piggyback on a particular diagnosis, better capturing just how sick patients are by creating more specific diagnosis-related groups.”

Careful documentation of complications present at the time of admission, co-morbidities, and the rationale behind care decisions are linked not only to reimbursement payments for hospitals, but also to quality of care and performance on public report cards, URMC says. Individual providers’ quality-of-care scorecards are also linked to their documentation.

For example, a provider may decide that, for good medical reason, a given heart attack patient shouldn’t receive the standard aspirin upon discharge. This is just one example of a routine “core measure” that CMS tracks to gauge how well hospitals adhere to best-quality practices. If the provider failed to note his or her logic in the patient’s record, the missing aspirin appears to be a sloppy oversight — not a calculated choice.

Faced with this changing landscape, Ali worked with physicians, mid-levels, and residents to better document care in a way that would translate into more thorough, appropriate coding. The result was Documentation Improvement Tips for Physicians and Medical Providers, a resource that provides practical documentation advice.

URMC conducted a pilot test of the resource with nurse practitioners (NPs) in a Med–Surg patient-care unit to evaluate how documentation practices would change over the course of a month. After 30 days, the average risk of severity of patients cared for by NPs was coded 2.90 — a 0.2 increase over the previous month’s 2.71. At the study site, every tenth of a point corresponded to almost $1 million in reimbursement.

“This was a small study, but it confirmed our suspicions that we were failing to fully document in a way that details the true acuity of the cases we take on,” said Ali. “In order to stay competitive, earn back payments that are rightly deserved, and safeguard a quality reputation, hospitals absolutely have to get better at this.”

Documentation Improvement Tips is available in several different formats. A new mobile app — URMC MDtips — is available free of charge from iTunes. An Android version will be available soon. The tips are also available for license from URMC in the form of a pocket reference booklet and a software package for hospitals.

Source: University of Rochester Medical Center; December 17, 2012.

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