Competition continues to rise across the healthcare industry as an increasing number of procedures shift away from hospitals toward the outpatient setting, with price transparency expected to amplify this trend when CMS' final rule takes effect on Jan. 1.
During a workshop sponsored by Nuance Communications at Becker's ASC Virtual Event on Oct. 14, Nuance's chief medical information officer, Lucian Newman III, MD, and Cathy Gorman-Klug, RN, quality service line director, discussed how ASCs can remain competitive and stay ahead of the curve by streamlining their documentation processes.
Five key takeaways:
1. The importance of procedural notes. Surgeons are not trained in the intricacies of coding, but it's critical that they do their due diligence when entering procedural notes. When procedural notes are not completed properly, it can negatively affect how physicians and facilities are reimbursed, which ultimately influences the practice's bottom line. "The quality and content of that procedure note ends up making a big difference," Dr. Newman said.
2. If it's not documented, it didn't happen. And if it didn't happen, you can't bill for it. This is the first thing many people learn in the healthcare industry, according to Ms. Gorman-Klug. This is especially pertinent in the event of an adverse outcome as healthcare facilities would not be able to defend themselves without proper documentation, which can impact "not only your revenue" but also "your reputation," she said.
3. Getting ahead of the data. If you're a busy surgeon, ASC or hospital with less than optimal reviews online — whether that be from CMS, your hospital or the ASC industry — it takes about two years to improve your data, according to Ms. Gorman-Klug. As competition continues to increase across the healthcare space, it's more important than ever for healthcare facilities to ensure that documentation is accurate and up to date.
4. New solutions tackling old problems. EMRs have been around for several years, but ease of use has rarely been indicated as the technology's most important feature, Dr. Newman said. Providers' technological battles with EMR and EHR systems have been no secret, so the emphasis for newer platforms should focus on ease of use. Navigated through a user-friendly interface, Nuance's Surgical CAPD system focuses on maintaining accurate documentation by streamlining surgeon workflow, managing high transcription costs and improving average accounts receivable.
5. Improved documentation. ASCs are known to be cost-effective, safe and efficient settings to have surgery. However, if ASCs continue to take patients away from hospitals, they may not be able to get away with doing "complete reporting" in the future, according to Dr. Newman, resulting in governing bodies beginning to compare ASC metrics in the same manner as hospitals. "The reality is that we have to do a better job of documentation," he said. "Capturing full specificity can improve quality scores, reputation and reimbursement."