Many larger facilities encourage providers to code their levels of service and procedures performed. Works with the encoder of your choice to code inpatient and outpatient charts and provides robust reporting to deliver actionable insight to support the best results from your CDI program. Without medical necessity, there simply is no CDI, regardless of how you look at it. Providing a snapshot from a high-level perspective will help providers gain a better understanding on the importance of documentation across the continuum of care. Conducts admission/continued stay reviews accurately, using the coding guidelines and documentation guidelines to clarify conditions/diagnoses and procedures for which inadequate or conflicting documentation exists. Clinical documentation sits at the core of every patient encounter, and Enjoin’s inpatient CDI program incorporates the next evolution of CDI best practice with strategies aimed at revenue recovery, revenue protection and overall documentation integrity and optimization to ensure consistently accurate coding and data integrity. Robeznieks, Andis. “Expanding CDI to Physician Practices: Five Documentation Vulnerabilities to Address in 2016.” Journal of AHIMA 87, no. For example: Section I.C: Chapter-Specific Coding Guidelines, This section addresses guidelines related to chapter-specific diagnoses and/or conditions. In recent years, many providers have become burned out and frustrated by EHRs, new reimbursement models, increased regulatory requirements related to quality, onerous query practices, and coding guidelines that vary by healthcare setting. The rule of thumb is for providers to report a complete list of diagnoses that captures all the conditions that warranted the outpatient services. All Rights Reserved. Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.1. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Clinical Documentation Integrity (CDI) Manager Childrens Hospital of The Kings Daughters 3.9 Norfolk, VA 23507 (Ghent area) Ensures the quality, consistency and timeliness of the facility coding and health record documentation comply with federal and state regulations. This new paradigm requires a wholesale shift in the mission of any CDI program, which should be aimed toward improving actual processes of clinical documentation and striving to achieve meaningful and lasting changes in physician behavioral patterns that optimally reflect communication of patient care, regardless of stakeholders, including third-party payers. keeps readers current on emerging Association—delivers best practices in With the use of EHRs in both hospitals and provider practices, “note bloat” and the use of cut/copy and paste has caused additional scrutiny on provider documentation. Californian Sentenced to Prison for HIPAA Violation, Watch List: 2021 Privacy and Security Trends, Information Blocking Implementation Roadmap, HIM’s How to Thrive Guide: COVID-19 Challenges Met, Lessons Learned and Advice to Forge Ahead, Information Blocking and HIPAA: Road to Compliance, Accurate Provider Data Governance Essential for Patient Care, Four Predictions about Health Data Management in a Post-Pandemic World, New COVID-19 Codes To Be Implemented Soon, HHS Proposes Modifications to the HIPAA Privacy Rule, Section I.A: Conventions, General Coding Guidelines and Chapter Specific Guidelines, This section addresses the conventions for ICD-10-CM. Number of diagnoses or management options, Amount and/or complexity of data required for review, Risk of complications and/or morbidity or mortality. A CDI professional can also be a valuable part of an analytics team. Career opportunities abound for CDI specialists who check job board sites and individual healthcare facility websites. The purpose of this Practice Brief is to describe documentation best practices and serve as a resource in effective and efficient clinical documentation practices without having a negative impact on patient care. The adage of “tell me how I am measured, and I will perform accordingly” applies in this instance. CDI supports positive outcomes in patient care, quality, cost, resource consumption, reimbursement, and revenue cycle processes. Educational efforts should also encourage providers to specify the acuity of every diagnosis, especially those only mentioned in the history of current condition section of the history and physical. In capturing the essence of the verbal discussion, timely notation of the reason for the query (exact date/time and signature), clinical indicators, and options provided should be recorded and tracked in the same manner as written queries and be discoverable to other departments and external agencies.” Provider response to the query must be documented in the permanent health record in order to be coded. Attainment of performance measures such as number of charts reviewed and number of queries issued virtually crowds out the CDIS’s ability to engage in actual physician engagement and coaching opportunities that facilitate actual achievement of integrity. The new mantra is quality over quantity when it comes to documentation, but the concern will always be: Was the full picture of the visit captured to support the level of service that was coded and billed, chronic conditions addressed, and problem list updated? Documentation should also be reviewed and validated at the time of entry. However, the documentation of the MDM often lacks specificity that could support a higher level. The symptom is reported (example: shortness of breath, cough, chest pain, etc.). These additional diagnoses may impact the patient’s overall risk score and treatment plan across the continuum of care, therefore it is very important for providers to be educated on the importance of documenting and reporting all diagnoses that are relevant and/or addressed during the visit and not to just report the four diagnosis pointers. Provides detailed project design documentation, project plans and process flows to present to leadership. For example, if a patient came in for an office visit for a cough and during the examination the provider documented that the patient is also treated with medication for diabetes and hypertension and has a history of right leg amputation status following a motor vehicle accident. To produce a medical record that is the most efficacious communication tool for all healthcare providers rendering care, in each case; To provide accurate, specific, detailed medical documentation to effect enhanced patient safety, as well as effectiveness of care efforts; To provide information for external reviewers of all types, free of ambiguity, inconsistency, or clinical incompleteness; To provide a medical record that is defensible relative to external audits; and. The three largest improper payment drivers are insufficient documentation, medical necessity, and incorrect coding. Providers should be validating and updating all documented conditions at each visit. Copyright © 2021  | ICD10monitor.com, a division of MedLearn Media, Inc. Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC, Clinical Documentation Integrity: Harvesting its Potential, Role-Based Versus Task-Based Clinical Documentation Integrity: A Major Determinant of Operational Performance, Preservation: A Fundamental Component to Revenue Optimization. Full-Time. This section provides general rules for reporting additional diagnoses. In addition, our CDSs are trained by the AMN Healthcare RCS Director of Education (an AHIMA Ambassador, MHA, RHIT, CCS, ICD-10 Trainer). Validates DRG assignment with medical record documentation, ICD-10-Official Coding Guidelines, and supporting clinical indicators. Barnette, Erin et al. The capturing of all diagnoses that are relevant to the treatment, socioeconomic, and/or psychosocial circumstances are important to accurately capture the patient’s clinical picture and potential health hazards, therefore providers should be educated on the impact of these additional diagnoses. Clinical documentation integrity in the time of COVID-19. A typical synopsis for job duties and responsibilities of a CDI specialist (CDIS) includes the following: A proactive delivery of provider education tailored to assist them in learning the art of documentation integrity will benefit all stakeholders. Director, Clinical Documentation Integrity at Revenue Cycle Business Services . A query may be initiated to clinically validate a diagnosis that a prior health record provided evidence to support particularly when clarifying specificity or the presence of a condition which is clinically pertinent to the present encounter supporting accuracy of care provided across the healthcare continuum. “Evolving Roles in Clinical Documentation Improvement: Physician Practice Opportunities.” Journal of AHIMA 88, no.5 (May 2017): 54-58. http://bok.ahima.org/doc?oid=302135. Providers should understand how their clinical documentation translates into data that is used for a variety of purposes. Requisition Number: 73875 Department: PRMO Location: Durham Type of Position: Regular Specialty: Patient Revenue Management (PRMO) Apply PRMO:, established in 2001, Patient Revenue Management Organization (PRMO) is a fully integrated, centralized revenue cycle organization supporting all of Duke Health, … CLINICAL DOCUMENTATION INTEGRITY MANAGER. platinum, gold, silver, bronze, catastrophic), The HHS-HCC methodology utilizes concurrent diagnoses to calculate the patient risk score and is further refined to reflect the expected risk adjustment population, The HHS-HCC risk scores represent member’s health status and selection of their benefit plan, Risk adjustment methodology for Medicare Part D and Medicare Advantage plans, The RxHCC methodology relies on certain diagnoses/conditions to predict the prescription cost for those diagnoses/conditions, The basic “HCC” approach was used to create the RxHCC model, The RxHCC model is similar to the Part C CMS-HCC model, Physician engagement in data analytics—they should be involved in ensuring data accuracy and leveraging it to make a difference when providing care to specific populations, Validate whether listed medications have associated diagnoses, Denial trends, medical necessity, documentation. Recently, two associations representing the CDI profession moved to change from clinical documentation improvement to clinical documentation integrity, to reflect a renewed focus upon integrity of the record. Providers can be better prepared by having enough time to learn and understand how these changes might impact their current document practices before January 1, 2021. Documentation will determine type of history: Documentation will determine type of exam: Documentation will determine level of MDM: On November 1, 2019, the Centers for Medicare and Medicaid Services (CMS) finalized a provision in the 2020 Medicare Physician Fee Schedule Final Rule. Although ICD-10-CM is used to report diagnoses in all settings, different guidelines apply for inpatient and outpatient settings, which may not be understood by providers working in both settings. While significant to both visit time and medical decision-making, these elements alone should not determine a visit’s code level. Who Has Rights to a Deceased Patient’s Records? The risk-adjustment model is budget neutral and insurers covering healthier patient populations are required to contribute to a risk-adjustment pool that will help other insurers covering a higher-risk patient population. Providers are also frequently using checkboxes to meet documentation requirements, especially in the outpatient setting. CMS measures the Medicare Fee-for-Service (FFS) improper payment rate through the Comprehensive Error Rate Testing (CERT) program. As the cost of healthcare premiums and copays have increased, many healthcare beneficiaries elected to enroll in managed care programs, which encourages efficient delivery of healthcare services. However, they cannot use both guidelines. ICD-10-CM Official Guidelines for Coding and Reporting FY 2020. https://www.cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf. Bonner, Dari and Karen M. Fancher. Patient presents with a symptom and no definitive diagnosis is made. Depending on the type of practice, such as specialty versus general medicine, E/M level distributions should be compared to national trends. Queries, whether performed verbally, by paper, or electronically, serve the purpose of supporting clear and consistent documentation of diagnoses during a patient’s visit. Can your clinical documentation integrity (CDI) teams prioritize work for scalability? Clinical documentation improvement, or clinical documentation integrity, may be defined as a process by which clinical indicators, diagnoses, and procedures documented in the medical record are supported by the appropriate ICD-10-CM and ICD-10-PCS codes. 29,190 Clinical Documentation Integrity Jobs. As already mentioned, accurate and precise provider documentation is more important than ever in the changing landscape of provider reimbursement and quality initiatives. publication of the American Health Apply to Document Specialist, Specialist, Clinical Director and more! As the Medicare Claims Processing Manual states, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf. Practice Brief: Evolving Roles in Clinical Documentation Integrity: A Provider’s Guide to the Art of Documentation, Reimbursement Methodologies and Quality Initiatives, Analytic Forces for the Ever-Important SDOH Battle, Clinical Decision Support Helps Combat Racial Disparities in Healthcare. Specifically, documentation should describe each condition as acute, chronic, exacerbated, or resolved to clearly convey its current status and relationship to the current episode of care. The accuracy of clinical documentation and reporting of these diagnoses may impact the patient’s/enrollee’s hierarchy, thus determining reimbursement. It’s important to identify key populations where there is risk, as well as social determinants of health for specific populations. JOURNAL of AHIMA—the official Develops collaborative relationships and promotes teamwork with co-workers and other departments. The clinical documentation in the health record must support the presence of all patient condition/diagnoses, along with the provider’s assessment and plan for management of each condition, especially chronic conditions. This is an area where outpatient CDI can be of great value. Centers for Medicare and Medicaid Services. The CDI Director will work with all members of the healthcare team to ensure timely and accurate clinical documentation within medical records. Our clinical documentation integrity (CDI) book measures up to this critical function, using a three-step approach that covers possible clinical indicators, risk factors, and treatments, enabling effective chart reviews and physician queries. These models provide incentives for providers to offer quality care at a lower cost. Therefore, it is important for CDI professionals to educate providers on the impact of documenting non-specific diagnoses and the ramifications of not documenting chronic conditions. I submit to you that simply reviewing a record and issuing a query that is responded to positively by the physician, coding of records with an identified CC/MCC, and billing of an “optimal” DRG bears no resemblance to clinical documentation integrity. This section also addresses format and structure of the classification. Documentation should support the level of service reported.”, Claim edits and correct coding initiatives. Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ACDIS provides the resources you need to become a Certified Clinical Documentation Specialist (CCDS) for a variety of specialized disciplines including education in anatomy and physiology, pathophysiology, pharmacology, medical coding guidelines, and more. Analyzes and interprets clinical data to identify gaps, inconsistences, or opportunities for improvement in the clinical documentation and appropriately queries the provider, using a compliant query based on American Health Information Management Association (AHIMA) guidelines for compliant query practice. Task-based indicators predicated primarily on the query process preclude the CDIS’s ability to engage in critical activities supportive of defined integrity. By focusing too closely on reimbursement, we are overlooking the vitally important component of true documentation improvement. Furthermore, many providers are being queried for additional clarifications that may or may not be appropriate, causing additional documentation discrepancies within a health record. Fran Jurcak, Chief Clinical Strategiest at Iodine Software with over 30 years of success in healthcare practice, education, consulting and technology shares thoughts on the impact of COVID-19 on clinical documentation integrity. Won’t you please join me in an effort to transform CDI to a system that truly makes a difference in patient care, and the saving of our hospitals and our jobs, in this day and age of hospital closures? These guidelines apply to all healthcare settings, unless otherwise indicated, Section II: Selection of Principal Diagnosis, This section indicates that the circumstances of inpatient admission always govern the selection of principal diagnosis, Section III: Reporting Additional Diagnoses. HCCs are made up of condition categories and the hierarchies are the compilation of related condition categories (CCs). What should the mission of CDI look like and consist of, for the purposes of coaching physicians in a quest to assist their becoming effective communicators of patient care, all while becoming more proficient in charting, saving precious patient care time? It will be helpful to educate providers on hierarchical condition categories (HCCs). It has never been more important to engage up front with clinicians and help CDI teams close the loop between clinical care and revenue integrity—all without increasing administrative burdens. These documented conditions are then translated into reportable codes and this reported data is then used to predict costs for the following year for Medicare Advantage and/or commercial enrollees. According to the Practice Brief, verbal queries should “include documentation of the conversations that occur with providers regarding documentation of reportable conditions/procedures. To think that queries and increased case mix index (CMI) is the end-all and be-all of CDI is a fallacy. 5 (May 2016): 22-25. http://bok.ahima.org/doc?oid=301436. Care coordination/population health data. They ensure accuracy and quality among medical coders, doctors, … Clinical Documentation Integrity and Clinical Documentation ExcellenceClinical documentation integrity must incorporate the recognition by the CDI profession that the medical record is a communication tool, first and foremost, and not a reimbursement tool, as today’s CDI model treats it as. We must respect the medical record with the patient in mind; our overall operating principle must consider the notion of the patient. Clinical Documentation Integrity (CDI) Specialist Salt Lake City, Salt Lake is the capital and most populous city in Utah. patient health information. The following tasks should be considered by the CDI team in both the inpatient and outpatient settings (for example, a large physician practice) when putting together an education program for the providers: Table 5: Examples of E/M Level Distributions. Often, name changes reflect little substance, and this is no exception. Well-established program: Brought to you by the Association of Clinical Documentation Integrity Specialists (ACDIS), this Boot Camp from the industry’s only dedicated CDI association provides the best-in-class education you expect. Documenting in the health record, especially in electronic health records (EHRs), is becoming an increasingly challenging task for many providers across the continuum of care. There are many facets to these models, but one point was clear in the literature, it requires engagement from providers, payers, and patients. November 21, 2019. Follows up on open queries to ensure physician response. AMA. Perform concurrent reviews and offer providers feedback to improve completeness and specificity in documentation to support ICD-10-CM/PCS, CPT, and HCC coding, Conduct chart reviews and any necessary provider education for compliance with quality reporting initiatives, Perform retrospective chart reviews for coding compliance and quality measures, Collaborate with team members to aggregate findings from clinical documentation reviews (both retrospective and concurrent) and design educational content and remediation strategies for both individual providers and provider groups, Coach the provider on opportunities for improving clinical documentation based on annual compliance review findings, Collaborate with team members on ways to improve EHR functionality in support of clinical documentation coding trends and requirements, Translate feedback from providers, CDI professionals, coding professionals, and compliance into content enhancements in the EHR, Design, test, and implement revised drop-down menus and other enhancements to assist providers in improved documentation and coding completeness, Collaborate with providers to improve existing standard note and template functionality, Collaborate with the EHR vendor to validate the embedded clinical terminology system within the EHR is appropriately mapping to the correct ICD-10-CM and/or SNOMED CT codes, Prepare physicians for the documentation changes effective in 2021, Review times documented for telehealth services, Schedule, prepare, and lead meetings with practices focused on documentation, coding, and quality performance gap closure, and develop and implement follow-up activity, Lead or provide education/training to clinical care (providers, nurses, etc.) Clinical documentation integrity (CDI) is a profession that has, in the past, been viewed as just a revenue-seeking program—but that’s not the full story. Prior encounter information may be referenced in queries for clinical clarification or validation if it is clinically pertinent to the present encounter. Facilitate documentation for the reporting of appropriatediagnoses, and procedures, as well as other types of health service related information (e.g. Current CDI key performance indicators preclude actual achievement of real integrity of the record, from both a quality and financial perspective. (example: acute systolic CHF, acute bronchitis, CAD with angina, etc.). CDI will be achieved through an unrelenting focus upon attainment of clinical documentation excellence. Guide and support projects, process, implementation and training teams. The Medicare Claims Processing Manual Chapter 23 – Fee Schedule Administration and Coding Requirements Section 10.3 – Outpatient Claim Diagnosis Reporting also provides additional guidance on what types of diagnoses can be reported on outpatient claims. 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Cdi programs: are they Poised for Effectiveness and Success of provider reimbursement and quality initiatives is risk, a... Of thumb is for providers to remember that the selected E/M level must be medically or! High-Level perspective will help providers gain a better understanding on the 1995/1997 documentation Guidelines when selecting the appropriate level the!, etc. ) ingrained in most hospital and healthcare facilities clinical indicators helpful educate. Bullet points are the compilation of related condition categories ( CCs ) areas of.... Should be compared to national trends service related information ( e.g and other.! Require extra healthcare services, medical necessity, there simply is no CDI, regardless how. Practices: Five documentation Vulnerabilities to Address in 2016.” Journal of AHIMA 87, no pertinent to the E/M visit. Condition categories and the hierarchies are the compilation of related condition categories and the hierarchies are compilation... 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