Achieving ‘Holistic’ Quality Documentation

As published in VBP Monitor (originally published in RACMonitor September 2014

Isn’t it great to imagine a health system in which the documentation shares a common thread and consistency across all payer types? One in which a patient with chronic systolic congestive heart failure has that diagnosis in their hospital medical record for Part A payment and within the physician record for Part B payment? Is it possible to have “Holistic” Documentation? This very well may be, as CMS continues to place providers on a path to meeting Meaningful Use, ICD-10, and Value-Based Purchasing/Pay for Performance/Accountable Care initiatives. Documentation has emerged into the need to document for payment and, ultimately, for survival.

Perhaps you are wondering, why use the term “Holistic” Documentation in this sense? To put it simply, Merriam-Webster defines holistic as “relating to or concerned with wholes or with complete systems rather than with the analysis of, treatment of, or dissection into parts;” synonymous with comprehensive and collaborative. Hopefully that definition has gotten your wheels turning, because it is powerful as we continue to explore this theory.

Unfortunately, most likely since the inception of our varying payment models for inpatient and outpatient physician services, not to mention specialty or post-acute services, we have been less concerned about the whole in the revenue cycle but more with the individual areas, hoping we would have some degree of financial meeting in the middle. This, of course, is not our fault. This thought process has been driven by payment methodology and our need/regulatory requirement to meet the standards of that model. Frankly, this mentality has focused on improved documentation within Part A with minimal impact within Part B. There has been no clear incentive for the two to look alike, be more specific within Part B, or to be looked at the same way. In walks Meaningful-Use, and ICD-10, Value-Based Purchasing/Pay for Performance/Accountable Care: new game, first quarter.

When you take a good look at all these initiatives, documentation is at the core of these areas, and of many consistencies in what we have been focusing on within hospitals for years. Part B is now being invited onto the documentation train, with the possibility to positively affect Part A. Gone are the times of looking at documentation for one payment model. We will need to join forces and work towards “Holistic”—Collaborative—Documentation to ensure we are teaching the same requirements across our healthcare systems and achieving individual results that are a part of the common goal and yield overall positive results for the whole. There are software tools out there that offer you solutions to work various data entry points, but are we properly utilizing these systems? This will be at the center of meaningful-use and population health management. How can we possibly achieve goals surrounding meaningful-use/PHM without capturing accurate documentation of patient conditions? Capturing documentation consistently will also reduce our ever-evolving audit risk. Focusing on documentation has become mandatory.

Realistically, there will be some diagnoses that will never match, as signs and symptoms are all we have if a more definitive diagnosis has not been established. That exists in some instances, but not all. Chronicity and acuity of diagnoses do exist, and should be fully reflected. Organizations should incorporate documentation within their strategic plans, with goals set to identify consistency within their documentation across patient populations and patients, especially for chronic conditions. Clinical Documentation Improvement Programs are present in many facilities but have not yet reached their full potential. I can recall stating the value of CAC tools and expanding CDI many years ago, and it appears these are finally gaining momentum. Ensuring you have sound, overall leadership of documentation initiatives within your institution is critical at this time; at the minimum, you need strong collaboration. Many of these initiatives are inpatient-focused, but outpatient and Part B needs attention as well for initiatives like PRQS (Physician Quality Reporting)/HCC (Hierarchical Condition Categories) models. Remember to think into the future and be progressive.

About the Author

Sharon Easterling began her career as a coder over 20 years ago and is now the Director of Ambulatory CDI with Huff DRG Services. Choosing to grow and learn wherever she worked, some of her experiences have included Inpatient and outpatient coding, payment validation, medical staff coordination, utilization review, and previous Director of HIM and Coding Departments. While working in these areas, Sharon assisted with HIS system development as well as documentation improvement initiatives since the early 2000s. Sharon has also developed and led the accreditation process for a Health Information Technology Program with 100% pass rate on certification exam. Sharon has the unique background of exposure to the acute and ambulatory setting throughout her career. Her past experience includes Corporate Asst Vice President. Sharon has chosen to share her experiences with other professionals through writing and educational sessions at the Local, State and National Level for NCHIMA, AHIMA, HFMA, and AAPC as well as other healthcare care entities. She currently sits on the Executive Board as a North Carolina Delegate for AHIMA; incoming President-Elect 2016-2017, American College of Physician Advisors Advisory Board, is a past member of the RAC Monitor editorial board, AHIMA Coding Community Practice Council as well as the CDI workgroup.

Contact the Author

To comment on this article go to

EDITOR’S NOTE: Author Easterling continues with a second installment of “Holistic Collaborative Documentation” in the next edition of RACMonitorEnews as she explains the “how” and “why” of PQRS/HCC opportunities.


An example of the impact of “Holistic” (Collaborative) Documentation

Last modified on Wednesday, 27 May 2015 20:58