As we move into the era of pay for performance, value-based purchasing, and bundled or global payments, our documentation must represent clearly the services we perform, and the rationale and medical necessity for our actions.

Patient care and documentation of that care given by any provider should have four elements of focus:

• The patient
• Clear communication with other health care providers
• Quality, evidenced-based care
• Best resource use

Let’s review these points one by one.

The Patient

First, information is gathered regarding the patient using all possible resources. Information is derived from the patient, family members and other caregivers, past providers or charts, and from direct questions to the patient about a particular problem or impairment. Depending on the chief complaint, subjective questionnaires are used, such as the Visual Analog Pain Scale, the Oswestry Disability Index, or the New York Heart Association, Classification for Congestive Heart Failure, etc. This information should be recorded completely in the most concise format.

Next, the patient is physically examined for pertinent elements utilizing in-office investigational tools and objective measures, depending on subjective information. For instance, based on the patient’s presenting problem, the examination may include: heart and respiratory rates, blood pressure, height and weight, and temperature; objective reflex testing; objective sensation testing; auscultation of the heart and lungs; palpation of organs and arteries; range of motion, strength testing and specialized tests for joint stability such as Lachman or McMurrray’s tests; tests for gait and/or balance, such as the Tinetti Performance Oriented Mobility Test; otoscopic or specialized eye exams, such as slit lamp testing, etc.

Outside testing may be used if required, and if a rationale for medically necessary tests is provided—beginning with the most conservative and least costly alternatives, and always keeping in mind which procedures can provide the most information regarding a particular condition.

The physician or other provider’s decision making then comes into play as a conclusion is reached regarding the patient’s care plan. This is the most important part of the process. The rationale for the care used must be justified and be clearly quality, evidence-based care that is medically necessary for this patient, at this time.

Clear Communication with Other Health Care Providers

The next step is to document what was done. A clear picture should be painted of the above actions and intentions in a way that is evident to anyone who reads the medical record.

Ask yourself: Does the picture provided in the documentation have all of the required elements of form and substance? Does it have a focal point? Does it bring all of the elements together toward a conclusion? Is the picture of the quality wanted, or does it need revision? In documentation, the picture painted should be clear to other providers or suppliers who will see the patient in the future.

For instance: What was the patient like before the injury or problem? What problems were presented? Did the patient have problems with function or activities of daily living? Were there problems with cardiovascular endurance? Were open wounds documented, and if so, were they accurately described and objectively classified? Was there a language barrier or cultural barrier that needed to be overcome to treat this patient? Was the primary and any pertinent secondary diagnoses clearly documented? Does the reader know what has been done to investigate the patient’s problems and why a resource was chosen over another? There should be a reason for every ordered test.

What was done to alleviate the problems? Was the care plan the best care possible as recommended by evidence-based practice and utilizing the least costly resources to help this particular patient with this particular diagnosis? There should be a reason for hospitalization, home health, nursing facility care, outpatient services, or referral to another provider. Will the reader know how long the treatment plan takes and what the expected patient outcome is when the treatment is concluded? There should be a reason for how often a patient is seen and for how long, and a reason for the expected time frame of when the patient needs to return for another visit.

In short: Was medical necessity for their care demonstrated and documented?

Quality, Evidenced-based Care

In 1991, the Institute of Medicine defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and knowledge and are consistent with current professional knowledge.” Similarly, in 2009, the Centers for Medicare & Medicaid Services (CMS) published a “Roadmap for Quality Measurement in the Traditional Medicare Fee-for-Service Program.” The agency defines quality measure goals as:

“Safety—where care doesn’t harm patients.

Effectiveness—where care is evidence-based and outcomes-driven to better manage diseases and prevent complications from them.

Smooth Transitions of Care—where care is well-coordinated across different providers and settings.

Transparency—where information is used by patients and providers to guide decision making and quality improvement efforts, respectively.

Efficiency—where resources are used to maximize quality and minimize waste.

Eliminating Disparities—where quality care is reliably received regardless of geography, race, income, language, or diagnosis.”

In its quality program, the Physician Quality Reporting Initiative (PQRI), CMS “works with organizations, such as the Joint Commission on Accreditation of Healthcare Organizations, National Committee for Quality Assurance, Hospital Quality Alliance, Ambulatory Quality Alliance, National Quality Forum, medical specialty societies and many other organizations and government agencies including the Agency for Healthcare Research and Quality and the Veterans Health Administration, in the development and compilation of measures that have been tested and found to be reliable and valid in assessing quality.”

In England, pay for performance is a reality for its general practitioners. Pricewaterhouse Cooper’s Health Research Institute’s article, “Paying for Performance – Incentives and the English Health System” states, “Pay for performance (P4P) is becoming an increasingly popular mechanism for incentivizing quality improvement globally. P4P is the only mechanism whereby quality metrics are explicitly linked to reward, however. As such, it is arguably the most effective mechanism for incentivizing quality over activity and/or volume.”

What does this mean for the provider in practice today? When the decision is made for a test or an intervention or procedure, it should have a rationale defined by agencies with tested measures that exhibit consistency and reliability in the treatment of patients. When work is documented, such measures must be used to demonstrate medical necessity and establish that the best possible care is provided.

The health care system is moving away from fee-for-service and pay for volume of care and toward pay for performance. The PQRI program will soon be based on pay for performance instead of pay for reporting, and voluntary efforts will soon be mandatory. It is moving toward value-based purchasing, where you may earn back reimbursement by demonstrating quality outcomes across a variety of service places (hospital, office, hospice, home care, etc.). This applies not only to Medicare, but more recently also to many third-party payers. The only way to show that this quality and performance is provided is through clear and precise documentation.

Best Resource Use

One element of the CMS “Roadmap for Quality Measurement in the Traditional Medicare Fee-for-Service Program” is efficiency, in which the resources used will maximize quality and minimize waste. CMS is leading us into bundled payments with some of their demonstration projects, where physicians and different providers will work with hospitals and others to provide the best quality solution for their patients utilizing the least resources. Another way to reduce health care costs as a portion of overall Gross National Product (GNP) might be a global payment system in which providers manage patients across all delivery systems, earning reimbursement for how they care for their patients. This might include specific diagnostic groups using very specific guidelines for all patients, reducing the volume of services delivered overall.

The issue of transparency is not quality alone. CMS is already publishing procedure prices in various hospitals and will expand this to physicians in the near future. As consumers become more educated in these areas, competitive pricing and quality will determine market factors for patient choice, which should decrease overall health care costs. Documentation should include the least costly resource reasons for utilizing one testing method, procedure, or product over another, as well as what is best for the patient.

Follow the Practice Standards of your professional organizations. Follow local and national Medicare and Medicaid rules if you choose to receive their reimbursement. Follow the documentation standards of your third-party payers. All providers should be participating in or should begin to participate in the PQRI initiative, as this is part of the future of health care.

What About Malpractice?

If every diagnostic test and new technology available isn’t utilized, how can malpractice lawsuits be avoided?

If some time honored treatment that always has been done to protect a practice is provided unnecessarily with increased services or prolonged treatment time, then increased services and increased revenue of the old fee for service system is gone and quality treatment in care suffers, which is a malpractice risk. When best practices guidelines as outlined by national agencies and professional societies are followed, and documentation is clear as to why one test is chosen over another for being the best and least costly test to diagnose a patient, then the patient has received quality care.

Back to the Basics

It’s the patient that counts. If the above care and documentation is provided, everyone involved in every health system that a patient has or will encounter should understand what was done and the rationale for choosing a particular treatment plan and can carry out appropriate care from there. Everyone benefits from knowing the test and assessment results, and treatments and placements to avoid repetitious, unnecessary, and costly procedures. Documentation should demonstrate the quality and medical necessity of the care plan chosen over the continuum of the patient’s care and lifespan.