Coding

Finding Common Ground on Physician Documentation

April 6, 2017 10:13 am

Leigh Williams, administrator, business systems, University of Virginia Health System, Charlottesville, Va., says that revenue cycle teams looking to improve physician compliance with documentation requirements should identify how better documentation supports physician priorities. The following are possibilities for common ground:

  • Financial stability for the health system that will lead to new clinical staff or new technology in their clinic
  • In the academic medical center setting, the importance of training new physicians how to document properly
  • Improved reputation of the health system in the community
  • Improved clinical care

“During an ICD-10 launch at my previous position as revenue cycle director and health information director at University of Mississippi Medical Center, I learned that physicians really cared about being able to see good information in the chart about what was going on with their patients,” Williams says. “They often did not want to take the time to write a lot of detailed information themselves, but they were heavily invested in getting it from other people.”

Williams and her team seized upon that insight to develop their physician engagement strategy. They pointed out that post-acute care providers need detailed information to care properly for patients discharged from the hospital and that, in the era of Open Notes, patients are reading and sharing their medical records.

“Physicians started to realize that the chart is being read by lots of people who are trying to take care of this patient, and it is important to have good information in the chart,” she says. “Then the whole health system started saying ‘This is something we want to do’—and that
was a win.”

Another win: meeting with department chairs to report specific documentation gaps that sabotaged ICD-10 coding and made it difficult for clinicians to know important information about the patient.

“The physician leaders coalesced around the things that they thought were good patient care and good documentation in their specialty,” she says. “Several times we heard physician leaders say, ‘We are doing what? That is completely unacceptable, and I’m going to talk to my clinicians about making sure their documentation meets our standards, regardless of what you are doing with coding.’”

See related article: Working with Physicians to Improve Documentation

Interviewed for this article:

Leigh Williams is administrator, business systems, University of Virginia Health System, Charlottesville, Va.

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