Documentation's Impact on Pay for Performance

(PYA Alert dated August 3, 2005)

Remember when you played “Leapfrog” with your friends and “HealthGrades” showed how well you performed in PE class? What about those extra dollars (Pay for Performance) you received with good grades on your “report card”? Things haven’t really changed that much, especially in the healthcare arena. More than ever, hospitals and physicians face the monitoring of their performance and, ever more frequently, public disclosure of the results of that monitoring. At best, payors are encouraging performance improvement through increased payment for quality services. At worst, they are punishing providers by restricting payment and access to their networks. In both instances however, data drives the process. If your data is flawed, your organization will suffer. How do you know if the data you are submitting truly reflects the level of care you are providing? How is this data generated? How can you measure its quality? These are all questions that must be answered if you want to be a “Top Performer” in the quality competition.

As you know, the data used by payors is generated through diagnosis and procedure codes that are assigned to a patient encounter based on physician documentation in the medical record. These codes provide a picture of the patient’s clinical condition and the care provided. If the documentation in the medical record is limited or poorly written, your coding professionals may be forced to assign codes which don’t indicate the complexity of the patient care or that the patient suffered from numerous underlying conditions that affected the response to treatment. In addition, these less specific, less complex codes result in less specific, less complex (lower paying) DRGs. Not only does your “report card” take a hit, so does your bottom line!

Lifelong learning is not just a cliché for coding professionals, it’s a way of life. At least quarterly, regulations are published that impact how codes are to be assigned and, if your coding staff does not fully understand coding guidelines, is not well-versed in the clinical aspects of code assignment, or has not kept up with the myriad of changes to coding rules, your “report card” takes another hit.

Should you find that your “report cards” do not reflect the quality of your care and that your bottom line seems to be “bottoming out”, let PYA help. We offer a number of solutions for your data quality issues and can customize a program to fit your needs.

"Not Satisfied With Your Performance Data? Let PYA Go To Work For You To Improve It While Also Improving Your Financial Performance!" Please contact Denise Hall at (800) 270-9629 for more information.

The information provided via PYA Alert, Tax Planning Alert, or Audit and Accounting Alert should not be construed as accounting, auditing, consulting, or legal advice on any specific facts or circumstances. The contents are intended for general information purposes only.  Please contact us at (800) 270-9629 to discuss your specific situation or to discuss any specific questions you may have.

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