At the Margins

Take some of the risk out of risk-based payments


As health care moves from volume- to value-based reimbursement, accurate coding practices have never been more critical. Now is the time to ensure that all appropriate codes are being included. Failing to paint a comprehensive picture of the health of overall patient population can have significant financial consequences.

Many organizations I’ve worked with rush to conduct a coding review. Unfortunately, a coding review alone isn’t enough. Instead, I’ve seen the best-of-the-best start much earlier in the process—with the physician.

A shift in focus can have dramatic effects, from both a financial and population health perspective. I’ve seen the power of this firsthand at Baptist Beaumont, a community hospital in Beaumont, Texas. Rather than merely conducting a coding review, executives there used one-on-one training to increase physician engagement in documentation improvement.

By shifting their focus to their physicians, they generated $4.2 million in additional reimbursement in the first seven months after physician training—not to mention greatly improving the integrity of the medical record.

While a coding review and strong clinical documentation improvement (CDI) team can help, it’s no substitute for accurate upfront physician documentation. Here are three key ways to effectively manage the transition to risk-based payments:

Physician focus

First and foremost, it’s critical to engage your physicians in documentation improvement. Documentation starts with the physician, and there’s no substitute for accurate and comprehensive information. If the physician fails to document appropriately, the coders won’t have enough information to present an accurate assessment of the care provided.

To improve documentation before it gets queried, engage your high-impact providers in one-on-one training to shed light on their key areas for improvement.

Ongoing monitoring

It can be tough to stay on top of your physicians’ documentation. But, regular reviews are critical. We’re seeing the best-of-the-best review their metrics monthly—specifically, case mix index, capture rate of complications and comorbidities, and use of unspecified codes.

You might be tempted to conduct a somewhat high-level review. But, that’s not enough. It’s crucial to monitor individual physicians’ documentation performance monthly. We’ve found that going one step further and sharing data directly with physicians enables them to make informed adjustments on an ongoing basis.

Continous CDI improvement

Don’t set up your CDI program and then forget about it. Ask yourself—are the goals we initially set still relevant, or are they totally out of date? What should our new goals be?

Most importantly, think through your current processes and training to ensure that you are proactively preventing poor documentation, not just retroactively correcting it.

Get the most bang for your CDI buck

Next, it’s time to improve relations between your physicians and clinical documentation specialists. The more providers get queried, the less likely they are to respond. Strengthen ties between these groups so physicians know whom to reach out to with questions, before they get queried.

I’ve seen how powerful this approach can be  through our work with CentraCare Health in central Minnesota. The CentraCare team partnered with our Physician Documentation Initiative and invited clinical documentation specialists to sit in on the physician training sessions. This tactic ensured that physicians and CDS were on the same page, and it gave the physicians a name and face to remember.

Ready to set your organization up for success under risk-based payments?

Email Morgan at HainesM@advisory.com to learn how we can help.

Baptist Beaumont’s $8.2M story

Sarah Horner, director of care management at Baptist Beaumont Hospital, explains how the Advisory Board helped her engage physicians in documentation improvement.

Watch the video