ASCs must optimize clinical documentation — Are your surgeons well-equipped?

Correct clinical documentation, a necessity for receiving appropriate reimbursement, can be challenging for surgeons who are experts at administering high-quality care but not necessarily trained coders.

This article is sponsored by Nuance Communications

While clinicians may think their procedure notes are complete, discrepancies between clinical documentation and coders' expectations continue to grow. ASCs see reimbursement dwindle when clinical documents are littered with inaccuracies and fail to meet coding standards. Days to collect, accounts receivables and claims denials are likely to rise, jeopardizing an ASC's bottom line.

In today's healthcare environment, ensuring accurate documentation is further complicated by rapidly changing guidelines and a shift from fee-for-service reimbursement models to pay for performance programs. More than ever, value-based care requires surgeons to accurately capture patient acuity and comorbidities.

"The quality of our care used to matter; now the quality of our documentation is as important for continuing your practice and having a high quality practice," Mercedes Dullum, MD, a regional medical director at Nuance, said during a June 16 executive roundtable at Becker's 16th Annual Future of Spine + The Spine, Orthopedic and Pain Management-Driven ASC Conference in Chicago.

How can ASCs optimize documentation without disrupting surgeons' workflows or invaluable face-to-face time with patients? A necessary step is making it easier for surgeons to document the right information in EHRs at the point of care.

Correct documentation where it matters — At the point of care

Providers increasingly feel burned out and regularly debate whether EHRs add value or harm to their clinical workflows.

A recent study in Family Medicine found an average ambulatory primary care visit lasts 35.8 minutes. Within that time frame, 7.5 minutes are spent on nonface time duties like entering patient information into EHRs. When clinical documentation fails to meet coding compliance, surgeons have to direct attention away from patients to double check whether their notes accurately capture patient acuity.

When coders send information to commercial payers or Medicare, it is increasingly difficult for surgeons to determine which code best captures the severity of their patient's illness, Lucian Newman, MD, CMO of Vincari and practicing general surgeon in Alabama, told executive roundtable attendees. "Ninety-nine percent of the time the doctors know the answer, but they don't know the question."

ASCs can support surgeons by ensuring correct clinical documentation happens in real time. Helping clinicians get documentation right the first time safeguards face time with patients and streamlines revenue cycle processes.

Vincari, a surgical computer-assisted physician documentation solution, helps surgeons capture details in real time that are ICD-10 and Joint Commission-complaint. Vincari avoids disrupting clinical workflows by learning physician's specific patterns through artificial intelligence.

Interfaced with EHRs, the solution saves physicians time by eliminating the need to validate notes with appropriate codes. It can be used across any specialty, and surgeons have the option to dictate notes. While documenting, surgeons receive automatic prompts when they may be missing clarifications to satisfy regulatory requirements, which can help minimize claim denials and delays. Quick access to daily surgery schedules and patient lists are also available on surgeons' mobile devices, a HIPAA-compliant feature which adds efficiency to a surgical team.

"We don't want physicians spending their time learning how to be a coder. We want them to take care of the patient," Dr. Dullum said. "We want them to document what they did, show how sick their patients are, and Vincari takes care of all of it on the back end."

Vincari generates a highly detailed report in less than 90 seconds, which is made immediately available to an ASC's EHR and medical staff. A copy of the report is distributed to referring physicians. The surgeon also receives an automated charge capture report he or she can use for coding and billing purposes. All of these functions are consistently updated in real time to reflect new regulations and guidelines, which are becoming increasingly complex as ASCs shift to value-based payment models.

ASCs' reimbursement solution is now equal parts quality care and coding

A shift from inpatient to outpatient facilities and increasing use of risk-bearing contracts are adding complexity to clinical documentation for ASCs. Ensuring patient acuity is correctly coded has never been more important and requires surgeons to be more detailed in their documentation.

Over the next decade, Sg2 predicts inpatient discharges will decrease 2 percent while outpatient volumes will likely grow 15 percent across the United States. As government and commercial payers scrutinize costs and push the shift to value-based care, outpatient surgery is expected to see an overall 11 percent increase from 2017 to 2022.

"As we're moving toward more outpatient ambulatory surgery, it's important to understand that we need to have appropriate documentation to cover how sick your patients are and the complexity of illness," Dr. Dullum said. "If we don't capture that, then you're going to lose out on both your quality rating and revenue generated for the center."

This is a difficult task for ASCs, which are not as accustomed to assuming risk as their hospital counterparts, according to Dr. Newman.

"ASCs have never been forced to try to prove the severity of illness of patients. ... Every hospital out there wants ASCs not to code their patients because it plays right into their narrative … that it's not important to create a better note because you're an ASC."

Vincari, which is constantly updated to reflect new coding guidelines and trends, maximizes reimbursement under value-based contracts by making correct clinician documentation a seamless part of surgeons' workflow. Vincari allows surgeons to view program performance by offering case tracking and flags improvement opportunities.

"[You're] speaking to the choir on the acuity ratings," a chief legal officer at a 29-bed surgical center in the Midwest told Dr. Newman. "Quality programs are all based on [acuity]. That's how we're getting paid these days."

Enhanced surgical documentation: The key to growing reimbursement

The more than 3,500 surgeons who have deployed the Vincari solution have seen a 92 percent reduction in retrospective queries. As more insurers pay based on value, the solution has adapted by collecting scores and generating summaries for certification and quality reports.

"The problem is the importance of what you focus your energy on has always been the professional care of patients. And unfortunately, that's not good enough anymore. Obviously that's imperative, but the way you record that becomes increasingly important," Dr. Newman said.

AI-powered solutions like Vincari ensure patient acuity is accurately captured and coded so surgeons do not have to siphon time away from patients. Nuance's robust implementation team ensures seamless integration of the solution into an ASC's EHR. As a result, surgical clinical documentation is enhanced — and appropriate reimbursement is realized.

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