Since 1998, government agencies have been releasing compliance program guidelines. All the while, these same agencies have warned health care entities ranging from large hospitals to private practices that they will be held accountable for inconsistencies or errors in their clinical documentation.

But with impending initial visits from recovery audit contractors (RACs) and sweeping changes to reimbursement expected in the next round of health care reform, improving the accuracy of those documents has become the most urgent of concerns for most HIM professionals. Those who've dragged their feet in preparation all these years shouldn't expect much sympathy.

"Honestly, it should've happened long ago," said William V. Walker, MD, FACP. Dr. Walker is certified in coding and compliance, and serves as a consultant at Midwest Healthcare Coding, LLC-an organization dedicated to clinical documentation improvement (CDI).

"For more than 10 years, the government has warned that they'll be holding us accountable-and now they're in full enforcement mode," explained Dr. Walker. "So to those people who say they want more time, my response is that they've had 10 years-so either tackle the problem or live with the consequences."

In that time, and even prior to the last 10 years, however, changes to clinical documentation have necessitated the re-education of both coders and physicians-that is, if they were ever trained in the first place. "One problem is that I can say I never received formal training in medical school as to how to properly communicate through medical records," explained Dr. Walker.

Luckily, he has since developed such knowledge and is able to lend a physician's perspective of clinical documentation to companies like HealthPort of Alpharetta, GA, where Cathy Brownfield, RHIA, CCS, is director of coding and auditing.

"Dr. Walker reviews charts that require a special review for us," explained Brownfield. "Additionally, he is able to educate other physicians on the subject."

Brownfield said that while CDI has always been a focus, the emergence of RACs and Medicare-Severity Diagnosis Related Groups (MS-DRGs) caused a resurgence in its clinical relevance. In her role as coder and auditor, responsibilities have increased two-fold.

"On the coding side, we have very thorough compliance," she explained. "But on the auditing side, we really have to be sure we're going above and beyond in our documentation."

So the challenge becomes conveying the importance of such attention to detail to physicians who by and large, by Dr. Walker's own admission, may not fully understand how crucial it has become to attain such accuracy.

"Our [physicians'] understanding of how this information would be viewed and evaluated was limited," he admitted. "Somehow, we were under the impression that it was only used for determining payment classification. In hindsight, we should've realized that if they're paying us, people have a right to know what everything means."

Nonetheless, using clinical documentation as a means of determining the quality of a physician's delivery of care is a

rather new concept in the medical community. In Dr. Walker's opinion, that means the focus needs to remain on education by physicians and coders alike. He believes currently employed coders need to work with practicing physicians, the partnering hospital and the medical society at-large to educate everyone on how to work with the current system-whether paper-based or electronic.

For this to occur, of course, coders will need to be well-versed in their own clinical skills. "Knowledge of anatomy, disease processes, etc . this will all be critical," said Brownfield. "Some coders know the coding rules, but lack knowledge in the clinical areas. We need to refine these skills so we can apply them to coding and know when to ask appropriate questions."

The Future of CDI

For those soon-to-be physicians still in medical school and the medical students of the future, the focus needs to switch to curriculum-based education-training these individuals to communicate with payers, lawyers and everyone who might be interested in what clinical documents contain.

It's why Dr. Walker has done his part by returning to his school to teach these concepts to current students. He feels that if everyone can get on the same page, the transition for the next generation will be much smoother.

"It's a simple matter of translation," he said. "There are multiple medical languages-physicians have their language, coders have their language, payers have their language-nobody is fluent in each of these languages, and it's unreasonable to expect the physician to write down each case in the manner of each audience."

It is reasonable, however, to expect physicians to step up as leaders in bringing all parties together to determine a universal language for documentation going forward. He feels coders also have a critical role in this process.

"Coders have valuable information that, if used properly, can benefit all who are involved," he explained. "But doctors currently lack the framework to insert this information-so it is reduced to random facts. If we can develop a partnership between physicians and coders, we can develop a framework and a context that will allow doctors to internalize this information, and incorporate it into their daily practice."

Teamwork is essential, but it only works if everyone covers their bases initially. "We all have a specific role and job to do," said Dr. Walker. "If we aren't able to accurately translate what we do, then everything else will be built on a false premise."

Brownfield reiterated the importance of internal auditing. "If you haven't been auditing, plan one soon," she stressed. "You need to know where you stand before anyone from the outside becomes involved."

Rob Senior is managing editor at ADVANCE.