Top 10 Best Practices for Compliant Use of Point of Care Technology

By Jason Jobes, SVP Solutions

Technology is a must for ensuring complete and accurate depiction of patient complexity. An emerging tool in the arsenal of many organizations are electronic prompts to the provider at the immediate point of care.

Unfortunately, the CDI/coding industry has a notable lack of regulatory guidance on compliant use of point of care technology, including for example the use of prompts for risk eligible conditions only (i.e., those that add weight in risk adjustment methodologies) vs. all known/suspected conditions.

To help fill this gap we have put together a Top 10 Best Practices for Compliant Use of Point of Care Technology. Please note that Norwood is not a regulatory entity and you should clear these suggestions with your compliance department prior to implementing.

But if you are planning to implement these tools we believe you find this list helpful.

1. Understand the source of prompt recommendations (i.e., problem list, past claims, suspected condition) at the point of care. We recommend segmenting out what automatically goes to the provider vs. clarifications sent by pre-visit review teams.
2. Know when and how the tool will prompt the provider. Some tools will prompt only particular visit types (i.e., annual wellness visits) or can be tailored by specialty for improved accuracy (i.e., prompting cardiologists for cardiac related conditions only, not every condition).
3. Ensure providers can opt out of addressing conditions when appropriate or not clinically relevant. Give your providers a pass for when they don’t know. Note that ignoring prompts 80-100% of the time is a problem.
4. Ensure that your policies and procedures outline recommended use of point of care tools, including provider expectations. For example, your policies should address what conditions providers are expected to address during visits, and what percentage.
5. Incentives should consider both what is addressed, and what providers reject from addressing. If a provider rejects a condition we recommend weighting that just as heavily as a condition that improves the RAF score, since both indicate effective use.
6. Develop education that is recurring, and provide ongoing feedback to providers. Even if you think you have done enough education, you are probably just scratching the surface.
7. Ensure that documentation fully supports the diagnosis being placed on a claim. At the end of the day, a diagnosis must stand on its own and be supported with sufficient documentation. Consider MEAT criteria for compliance.
8. Conduct post-visit coding reviews for high-risk diagnoses placed on claim via point of care tools. Some organizations are using NLP technologies to review any diagnosis captured for the first time in a calendar year to ensure the documentation supports it.
9. Perform audits to ensure appropriate use of technology and confirm alignment of documentation and coding. If for example a prompt is only being accepted 5-10% of the time, you may want to screen it out.
10. Review any manually added prompts (i.e., CDI queries) for accuracy and query compliance. Adhere to the latest ACDIS-AHIMA query practice brief as well as any internal policies you’ve developed.

Need a compliance review of your risk adjustment coding or E/M billing? Consider Norwood. We offer reasonably priced, flexible, custom solutions to meet your organization’s needs. Contact us at consulting@norwood.com to schedule a no-strings attached call.