On January 26, 2015, CMS released three Fact Sheets solidifying their commitment to the transition from a volume based Fee-for-Service to delivery model to one based on value, quality, and population health. A healthcare provider’s ability to successfully operate under and meet the challenges associated with this delivery model transition will be directly dependent upon the quality of clinical documentation. Optimal clinical documentation accurately reflects the patient’s clinical acuity, the reason for the patient encounter and rationale for or service ordered and care provided (i.e., medical necessity); accurate expression of clinical judgment, evidence-based medical decision making and thought processes; diagnostic statements documented to the highest specificity possible and with all supporting criteria clearly documented, all of which are necessary to demonstrate and accomplish smart effective care choices.

Now is an ideal time to take an inventory of the quality and effectiveness of your clinical documentation as part of a broad-based clinical documentation improvement initiative that includes both the inpatient and outpatient arena.

If you have a formal clinical documentation improvement program initiative already in place, ask yourself whether your program contains the fundamental structure and tools to effectively and efficiently capture the necessary clinical documentation required with the transition away from Fee-for-Service. Thepresent focus of most CDI programs is on the revenue inherent with CC/MCC capture and resulting case mix and revenue impact. Unfortunately, current revenue-focused approach to C is of limited value in meeting the goals and objectives of a value–based and quality-oriented population health management delivery model.

The CMS fact sheets can be accessed at the following links: