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The Gaps in The Guidelines And Their Implications For Urgent Care Facilities

The latest data from the Journal of Urgent Care Medicine predicts that the urgent care market will exceed $26B by 2024 – a growth rate of 23% from 2018. This shows the vital role urgent care facilities play in the healthcare ecosystem and their increasing popularity due to convenience and shorter wait times.

Urgent care practices, however, are among several specialties we identified in our recent white paper, Making Sense of the 2021 Documentation Guidelines, that were more susceptible to guidelines misinterpretation.

Consider the frequency of this scenario – a patient comes into an urgent care facility with a problem they thought would resolve on its own but hasn’t done so. The clinical documentation guidelines indicate these types of problems fit the progression, exacerbation, or side effects of chronic problems. But the patient’s problem isn’t chronic. It’s acute.

While the guidelines don’t exclude acute problems, they also don’t specifically address them, and the ambiguity leads to widespread under-interpretation of their meanings. How do we classify these worsening acute illnesses, illnesses that don’t follow the standard course or illnesses that fail to self-resolve or respond to limited or OTC treatment?

Reventics’ CDI team spent over 60 days re-interpreting and using these guidelines in real-time to provide urgent care facilities feedback on their clinical documentation to improve accuracy, compliance, and reimbursement.

Regarding the specific scenario mentioned earlier, we suggest that when implementing the guidelines in an urgent care setting, eliminate all judgments of chronic or new at all decision-making levels. Acute cases create additional complexity whether they’re acute chronic cases or acute new cases. For example, when determining what number or complexity of problem is associated with each level, anywhere the guidelines say chronic, add the words acute, sub-acute, and any indication of new to read new or established.

For example, for codes 99204 and 99214, the first three bullets in the guidelines would read:

  • 1 or more chronic, acute, sub-acute illnesses with exacerbation, progression, or side effects of treatment; or
  • 2 or more stable chronic, acute, sub-acute illnesses; or
  • 1 undiagnosed new or established problem with uncertain prognosis; or

For more information regarding these suggestions regarding the guidelines, as well as tables with additional language addressing many of the potential difficulties of implementation, please download our white paper, Making Sense of the 2021 Documentation Guidelines.

To learn more about how Reventics’ CDI solution can help improve clinical documentation by educating your physicians and implementing these guidelines, get a RevCDI demo.