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Clinical Documentation – In It for the Long Haul

Publish Date
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July 14, 2021

While it is hard to believe that we have been in the midst of COVID-19 for over a year now, from a clinical documentation perspective the reality is that we are just beginning. Health information management (HIM) and revenue cycle professionals alike are embarking on a journey that will have many twists and turns in the future; we all need to be prepared to be in it for the long haul.

The foundation that healthcare providers must rely upon is their clinical documentation. The accuracy of the documentation within a patient record is more critical than ever before. This applies to all records in all patient care settings – from physician offices and specialty clinics to acute and long-term care facilities. Some patients that had COVID-19 sadly lost their battle to the virus. Other patients recovered after a few weeks with little to no lingering effects. However, there are also many patients who had COVID-19 and are still dealing with the aftereffects. Their journey continues and many of them are now being referred to as “long-haulers.”

COVID-19 long-haulers are a unique group of patients who suffer a diverse range of symptoms. Some suffer serious, chronic conditions while others suffer more common issues that can arise at varying times after recovering from the virus. The one thing they all have in common is their symptoms are tied to COVID-19 – and their clinical documentation must reflect their health and care history accurately.

 Memory Loss Concentration issues Brain fog
 Fatigue Joint/muscle pain Depression/anxiety
 Blood clots Organ damage  Increased heart rate
 Loss of smell or taste  Fever  Cough
Difficulty breathing Dizziness  Chest pain

Focus on Clinical Documentation for Accurate Coding and Billing for COVID Long-Haulers

Clinical documentation has always served as the foundation of patient care. The documentation within a patient record should present “The True Clinical Picture” of the patient and the care provided. Additionally, the record should also contain key information regarding chronic and underlying conditions that may impact current or future care.

For many HIM and revenue cycle professionals, the issues experienced by COVID-19 long-haulers look very familiar. Chronic and underlying conditions are well known to us. However, the addition of COVID-19 to the issues above is still materializing. The healthcare industry continues to gain more data by the day and payers and governmental agencies continue to learn and adjust payment requirements on the fly. These ongoing changes present both a challenge and an opportunity for the revenue cycle.

Did you know… According to the Centers for Disease Control and Prevention, the 1918 Influenza Pandemic was similar to COVID-19 in that it occurred in three separate waves that lasted from 1918 through 1919? The first mention of influenza appeared in April 1918 when 18 severe cases and 3 deaths were reported. The second wave between September and November 1918 was highly fatal. The third wave occurred in the winter and spring of 1919 and subsided by summer.

Healthcare organizations must acknowledge that the lasting effects of COVID-19 will be with us for some time to come. As a result, the clinical documentation, coding, and billing must be a primary focus for all team members. This is certainly not a time to be “penny wise and pound foolish” as the saying goes. Organizations must focus on the bigger picture now so that they are not further impacted in the future because of deficiencies in documentation and billing practices that exist today.

Over the last year, organizations have also dealt with insurmountable regulatory change, including but certainly not limited to:

  • Countless new COVID-19-related CPT and ICD-10 codes with varying effective dates
  • Evolving guidance around beneficiary cost sharing, place of service codes, and telehealth modifiers
  • Insurance waivers with varying effective dates
  • New query forms
  • New COVID-related coding guideline

Regardless of the approach, your organization selects to tackle all these changes, it is critical that an approach is determined, and that it is taken to heart across the organization.

Consider a Clinically Integrated Revenue Cycle

One such approach is developing a Clinical Integrated Revenue Cycle. COVID-19 patients, long-haulers, and our patient population require thorough and complete documentation as well as compliant coding. Billing correctly the first time around will save the organization time and money in the long run. One of the first steps is to unite coders and CDI staff. By integrating these teams, creating a Clinically Integrated Revenue Cycle, and proactively addressing potential denials, organizations will be able to boldly state that they are “in it for the long-haul” for their patients, families, and community.

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