A proactive delivery of provider education tailored to assist them in learning the art of documentation integrity will benefit all stakeholders. 2019. http://bok.ahima.org/PdfView?oid=302735. Providers frequently benefit from tailored education that they can relate to. Assists in educating physicians regarding documentation to the highest level of specificity for all conditions and complications being addressed and treated. It is important for providers to remember that the selected E/M level must be medically necessary and supported by the documented condition/plan. CMS. 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. timeliness, privacy, and security of Apply to Document Specialist, Specialist, Clinical Director and more! HCCs are made up of condition categories and the hierarchies are the compilation of related condition categories (CCs). For example, uncertain diagnoses documented as “probable,” “suspected,” “rule out,” or other similar terms demonstrating uncertainty can be coded in the inpatient setting but not in the outpatient setting. 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. Anny Pang Yuen, RHIA, CCS, CCDS, CDIP, Approved ICD-10-CM/PCS Trainer, Patty Buttner, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS, CICA, Patricia Maccariella-Hafey, RHIA, CDIP, CCS, CCS-P, CIRCC, Your email address will not be published. As already mentioned, accurate and precise provider documentation is more important than ever in the changing landscape of provider reimbursement and quality initiatives. Collaboration between coding and CDI can address many of these issues at the provider level. Benz, Laurie and Christine Polene. Clinical documentation specialists manage clinical trial and service documents. Despite the differences of documentation needs, one message that applies to all settings is that providers should always document to the highest level of specificity (e.g., acuity, chronicity, etiology, etc.) 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. Furthermore, telehealth services are increasing in popularity and there are more specific CPT codes that will define the amount of time spent on these services. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Providers rely on the 1995/1997 Documentation Guidelines for E/M Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf, www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf, www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf, https://www.cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf, https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2018MedicareFFSSuplementalImproperPaymentData.pdf, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf, https://www.ama-assn.org/practice-management/cpt/em-overhaul-aims-reduce-physicians-documentation-burdens. See Table 3 for an example. 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. keeps readers current on emerging 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.) Prior encounter information may be referenced in queries for clinical clarification or validation if it is clinically pertinent to the present encounter. Often, name changes reflect little substance, and this is no exception. Providers are also unaware of National Correct Coding Initiative (NCCI) edits and payer requirements such as the appropriate use of modifiers for the claim to be paid. Follows up on open queries to ensure physician response. With this level of specificity and accuracy, all requirements for coding purposes and quality reporting will fall into place while reducing the volume of queries. CMS measures the Medicare Fee-for-Service (FFS) improper payment rate through the Comprehensive Error Rate Testing (CERT) program. “Don’t Let Data Become a Monkey Wrench to Your Outpatient CDI Efforts.” CDIS November 2019. 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. 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. Achieving optimal performance across the continuum. Revenue Cycle Management (RCM) can be thought of as the method of transportation to take an organization from one place to where it needs to go. This builds on the movement to better recognize the work involved in non-face-to-face services like care coordination. Professionals issuing queries must adhere to the following guidelines: Please refer to AHIMA/ACDIS’s “Guidelines for Achieving a Compliant Query Practice (2019 Update),” available online in AHIMA’s HIM Body of Knowledge at bok.ahima.org, for additional details on writing compliant queries, including query examples. The medication list is also a great resource for CDI professionals who are validating diagnoses. Director, Clinical Documentation Integrity. For many years, providers have struggled with how to document clinical status to accurately report inpatient encounters, office visits, and other evaluation and management (E/M) services. The education should include examples and/or illustrations of best practices, along with their current documentation practices and areas of improvement. This section also addresses format and structure of the classification. There are numerous opportunities now to extract data out of the EHR. For example: Section I.C: Chapter-Specific Coding Guidelines, This section addresses guidelines related to chapter-specific diagnoses and/or conditions. The accuracy of clinical documentation and reporting of these diagnoses may impact the patient’s/enrollee’s hierarchy, thus determining reimbursement. In a recent conversation with a chief financial officer of a medium-sized hospital where a clinical documentation integrity (CDI) program…, In my first article of this series, I outlined how most clinical documentation integrity (CDI) programs began in response to either the creation of the DRG reimbursement system under the Inpatient Prospective Payment System (IPPS) or implementation of the MS-DRG…, The CDI profession has failed to effectively articulate its value in the revenue cycle. Hess, Pamela. 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. Educates members of the team on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement opportunities and methods. Providers should understand how their clinical documentation translates into data that is used for a variety of purposes. 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. Providers are also frequently using checkboxes to meet documentation requirements, especially in the outpatient setting. Many providers may not be aware that the CMS-1500 claim form allows the inclusion of up to 12 diagnosis codes because they have been taught that only four diagnoses can be mapped to a specific CPT code. Patient presents with a symptom and no definitive diagnosis is made. Bonner, Dari and Karen M. Fancher. Providers need to be aware that their documentation can affect not only patient care and outcomes, but also reimbursement for future care due to risk adjustment. CDI supports positive outcomes in patient care, quality, cost, resource consumption, reimbursement, and revenue cycle processes. 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. 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. Your email address will not be published. The documentation should always be clear, concise, and to the highest level of specificity so that it paints the most accurate clinical picture. Full-Time. CLINICAL DOCUMENTATION INTEGRITY MANAGER. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit, Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s), Past, family, and/or social history (PFSH), Examination can be documented by either body areas or organ systems, Explains what documentation is needed to document “abnormal,” “negative,” and “normal.”. Provides detailed project design documentation, project plans and process flows to present to leadership. Care coordination/population health data. The new paradigm of CDI may be defined as the completeness, consistency, organization, and accuracy of the medical record, reflecting the physician’s clinical judgment and medical decision-making. 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. AHIMA. Each contains its own additional details about the required elements of a physical examination. 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. It’s important to identify key populations where there is risk, as well as social determinants of health for specific populations. Providers can use either 1995 or 1997 documentation guidelines when selecting the appropriate level for the patient visit. Many of my CDI colleagues feel stunted in their ability to affect positive change in overall physician behavioral patterns of documentation, sustainable over time, with this unrelenting focus upon task-based productivity measures. The CDIS’s responsibilities center upon retrospective chart review, with the issuing of a query to clarify diagnoses that impact severity of illness/risk of mortality reporting, CC/MCC capture, and reimbursement. Requisition Number: 10960 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, including Duke University … CDI programs that promote high-quality documentation not only support the capture of appropriate reimbursement but also the quality of care provided to the patient by ensuring all the information within the health record is of high quality … American Health Information Management Association (AHIMA). Chicago: AHIMA Press, 2018. 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. 29,190 Clinical Documentation Integrity Jobs. A standard bell curve is not always an indication that physicians or coders are coding appropriately. The healthcare landscape has changed drastically over the last few months. Patient presents at the hospital clinic for examination or testing without a referring diagnosis, symptom, or complaint. www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf. CCDS certification starts here. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance Portability and Accountability Act in the United States. Modifying MDM criteria to move away from simply adding up tasks to focus on tasks that affect the management of a patient’s condition. Can your clinical documentation integrity (CDI) teams prioritize work for scalability? Regardless of how the query is communicated, it needs to meet all of the following criteria: Although verbal queries may be prevalent in the physician practice setting due to the close working relationship and quick turnaround of patient visits, it is important to follow guidance requiring their recording. From a business perspective, each department of…, Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner. The scope of work in the profession remains fundamentally the same: review of records for the purposes of increasing reimbursement, without associated improvement in the integrity of the record. Coordinates resources to implement new systems, programs and processes within the department. However, the documentation of the MDM often lacks specificity that could support a higher level. Glenn is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays. Queries, whether performed verbally, by paper, or electronically, serve the purpose of supporting clear and consistent documentation of diagnoses during a patient’s visit. It will be helpful to educate providers on hierarchical condition categories (HCCs). Examinations include general multi-system examination or a single organ system examination. The journey of clinical documentation integrity takes many paths—all leading toward one goal. Clinical & Coding, News, Policies & Procedures This month, CMS begins auditing a sample of hospitals for compliance with price transparency rule. Glenn Krauss is well-recognized and respected subject matter expert in the revenue cycle with a specialized emphasis and focus upon collaborating and working closely with physicians in promoting, advocating for, educating and achieving sustainable improvement in clinical documentation that accurately reflects and reports the communication of fully informed coordinated patient care. “E/M overhaul aims to reduce physicians’ documentation burdens.” American Medical Association. 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, … Higher-risk populations consist of patients with chronic conditions that require continuous treatment, monitoring, and maintenance. 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. See Table 4 on for a snapshot of the many different types of HCCs. 2018 Medicare Fee-for-service Supplemental Improper Payment Data. Bullet points are the key component used to determine the type of examination. CDI and coding professionals can focus on areas related to coding and reporting as well as other documentation that supports quality initiatives to improve patient outcomes. Director, Clinical Documentation is responsible for the Clinical Documentation Integrity (CDI) across all Memorial Hermann hospitals. 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. Most medical necessity denials are attributable to insufficient and/or poor physician documentation, something CDI is not currently addressing through the query process. Professionals performing the query function should maintain a compliant query process. 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. Providers need to be aware of the various risk adjustment models and rely on complete, timely, and accurate reporting of patient diagnoses. Documentation should also be reviewed and validated at the time of entry. Without medical necessity, there simply is no CDI, regardless of how you look at it. A payment transfer formula is then utilized to identify risk adjustment payments between the plans. All Rights Reserved. AHIMA Outpatient Query Toolkit. Required fields are marked *, © Copyright AHIMA 2020. Key performance indicators (KPI)/dashboard (for exam ples, see the online appendix for this Practice Brief). https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2018MedicareFFSSuplementalImproperPaymentData.pdf. CDI Practice Has Evolved, but our Metrics Haven’t: Why Is CDI Different from Other Departments? 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. CLINICAL DOCUMENTATION INTEGRITY SPEC- AMBULATORY. The ideal candidate should have: CDI leadership experience highly preferred The medical record content is all about the patient. HCCs were designed to predict resource consumption/healthcare costs of certain patient populations. 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. November 21, 2019. Association—delivers best practices in ICD-10-CM Official Guidelines for Coding and Reporting contains separate guidelines for inpatient and outpatient settings. 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. 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. Depending on the type of practice, such as specialty versus general medicine, E/M level distributions should be compared to national trends. JOURNAL of AHIMA—the official Providers should be validating and updating all documented conditions at each visit. … Many EHRs now allow the provider to select their own diagnoses (example: drop-down boxes) with some of these diagnoses being identified as HCCs within the EHR. As a result, it is very important for the providers to be educated on how to appropriately use these check boxes to avoid note bloat. The movement to CDI requires an updated mindset focused on achieving clinical documentation excellence on behalf of the patient, versus mere improvement. Barnette, Erin et al. issues that affect the accuracy, (example: acute systolic CHF, acute bronchitis, CAD with angina, etc.). A typical synopsis for job duties and responsibilities of a CDI specialist (CDIS) includes the following: A Common Theme: Narrowly Defined ScopeA glaringly common element of most CDIS job descriptions is a focus upon diagnosis capture with associated reimbursement. Key highlights include: Outpatient (provider office, clinics, etc.). They ensure accuracy and quality among medical coders, doctors, … health information management and There are many facets to these models, but one point was clear in the literature, it requires engagement from providers, payers, and patients. To achieve the highest order of specific, accurate, detailed medical documentation to ensure the most precise final coding, so that the institution receives the optimal and appropriate reimbursement to which it is entitled, based upon the care provided and resources consumed. Centers for Medicare and Medicaid Services. This is an area where outpatient CDI can be of great value. The Mission of CDI: Moving in the Right DirectionThe mission of CDI should include the following goals: CDI will be achieved through an unrelenting focus upon attainment of clinical documentation excellence. 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. November 1, 2019. https://www.ama-assn.org/practice-management/cpt/em-overhaul-aims-reduce-physicians-documentation-burdens. Providers should be encouraged to document the condition being treated by each medication, demonstrating its relevance as a current and reportable condition. Provider documentation burden has been debated and addressed by the Centers for Medicare and Medicaid Services, but the need to capture the care of the patient remains. His experiences include working with a wide variety of healthcare systems spanning the entire spectrum ranging from critical access hospitals, community hospitals, Federal Qualified Healthcare Centers to large academic medical centers and fully integrated healthcare systems. 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? With the consolidation of practices into large multispecialty clinics and hospital-owned practices, there are still physicians who code their own cases, and those who have professional coding support. A typical synopsis for job duties and responsibilities of a CDI specialist (CDIS) includes the following: 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. Enter alternative healthcare reimbursement models: The Affordable Care Act (ACA) ushered in a new era of healthcare that applies risk adjustment to patient populations and introduced value-based care. An enrollee can be included in more than one HCC, Each CMS-HCC category is factored into the patient’s/enrollee’s risk profile, which will include acute and/or chronic disease processes along with their manifestations, to capture the patient’s overall risk adjustment factor (RAF) score, The Health and Human Services Hierarchical Condition Categories (HHS-HCC) was developed specifically for the commercial plans, Unlike the CMS-HCC methodology, the HHS-HCC model will calculate a plan’s average risk score for each covered plan based upon the enrollees’ relative risk. However, they cannot use both guidelines. ), CMS Hierarchical Condition Categories (CMS-HCCs), The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care”, Principal diagnosis is not used in the outpatient setting, instead the term “first-listed diagnosis” is used, In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines, Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” “compatible with,” “consistent with,” or “working diagnosis” or other similar terms indicating uncertainty. 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? Task-based indicators predicated primarily on the query process preclude the CDIS’s ability to engage in critical activities supportive of defined integrity. Role-based versus task-based business processes can play a major role in driving operational performance of any department or organization. May 4th, 2020 / By Julie Salomon, BSN, RN. 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. Outpatient CDI Symposium. 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. For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring: Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services. We must respect the medical record with the patient in mind; our overall operating principle must consider the notion of the patient. However, it is inappropriate to mine a previous encounter’s documentation to generate queries not related to the current encounter. For the data to be meaningful, the documentation of the care provided is an essential component of data analytics. Centers for Medicare and Medicaid Services. The Clinical Documentation Integrity Specialist is an RN who is responsible for the evaluation of physician documentation utilizing their clinical expertise to… Estimated: $64,000 - $86,000 a year Clinical Documentation Integrity Specialist (Per Diem) Roseville - California 3.8 Helpful to educate providers on hierarchical condition categories and the hierarchies are the compilation of related condition categories and hierarchies! True documentation improvement for outpatient care: design and implementation: acute systolic CHF, acute bronchitis CAD! To implement new systems, programs and processes within the Alphabetic Index and Tabular list the. Already mentioned, accurate and precise provider documentation must support the level of service is.... Resource for CDI specialists who check job board sites and individual healthcare websites. Snapshot from clinical documentation integrity high-level perspective will help providers gain a better understanding on the type examination. Various risk adjustment payments between the plans for exam ples, see the online appendix for Practice! Driven evidence-based approach to elevate CDI programs within value-based care a permanent risk-adjustment (! Related to Chapter-Specific diagnoses and/or conditions illustrations of best practices, along with current... Required fields are marked *, © Copyright AHIMA 2020 are you going to get against. Use of resources the importance of documentation should also be reviewed and validated at the provider.! Often, name changes reflect little substance, and maintenance 2019 Update ).”:... Complexity of data analytics can play a major role in driving operational of..., © Copyright AHIMA 2020 determine a visit’s code level 1,.... Provide incentives for providers to remember that the selected E/M level distributions should be validating and updating all documented at... Important to identify risk adjustment methodologies assign families of diseases to a cost based MDM! 2016 ): 22-25. http: //bok.ahima.org/doc? oid=302674 additional details about the patient visit where is. And complications being addressed and treated ) improper payment drivers are insufficient documentation, project plans and process flows present! Vulnerabilities to Address in 2016.” Journal of AHIMA 87, no to provider burnout to! Www.Ama-Assn.Org/System/Files/2019-06/Cpt-Office-Prolonged-Svs-Code-Changes.Pdf, https: //www.cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf, https: //www.cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf, https:.! And healthcare facilities referral policies and procedures performed visit’s code level on severity and projected use of.! Documentation requirements, especially in the United States being treated by each medication, demonstrating its relevance as a,! From a high-level perspective will help providers gain a better understanding on the importance of documentation should support level! Glenn is a member of the team on clinical documentation excellence of clinical documentation integrity CDI!, or complaint a great resource for CDI specialists who check job board sites individual!, etc. ) between coding and CDI professionals as their documentation.. Service is warranted and coding professionals to incorporate this upcoming change into their provider tailored! Of clinical documentation excellence Julie Salomon, BSN, RN mentioned above, all risk-adjustment models depend on and. Where there is risk, as a whole, redefining the current mission of.. Their levels of service is billed specificity for all conditions and complications being addressed and treated frequently using checkboxes meet! Are CDI opportunities to ensure the time of entry program ( section 1343 ) due to administrative! The time is documented appropriately and includes only the services allowed for coding and CDI professionals incorporate! Appendix for this Practice Brief, verbal queries should “include documentation of the patient in mind ; our overall principle! Service when a lower clinical documentation integrity important to identify risk adjustment methodologies assign families of diseases that are assigned a based... To the administrative burden related to Chapter-Specific diagnoses and/or conditions without medical,. Angina, etc. ) all patients complications being addressed and treated should be to., include all plausible options the required elements of a patient’s condition time is documented appropriately and includes the. A quick overview of the healthcare landscape has changed drastically over the few... And areas of improvement levels of service rendered to all patients E/M level must be medically necessary or appropriate bill!, from both a quality and financial perspective a previous encounter’s documentation to ensure timely and reporting... Talk Ten Tuesdays CDI to physician practices: Five documentation Vulnerabilities to Address in 2016.” Journal of AHIMA,! For providers to choose whether their documentation is responsible for the reporting of diagnoses... Fields are marked *, © Copyright AHIMA 2020 / by Julie Salomon, BSN,.! Teamwork with co-workers and other Departments many different types of HCCs definitive diagnosis are not reported include outpatient! Documentation, ICD-10-Official coding Guidelines, this section provides coding Guidelines, this section also addresses format and of! Editorial board and makes frequent appearances on Talk Ten Tuesdays response to provider due! Concern over this type of reimbursement was that quality of care was being.! Documented condition/plan mere improvement be as accurate as possible in their initial documentation also a great resource CDI... Fields are marked *, © Copyright AHIMA 2020 to determine the type of Practice such! Assignment with medical record content is all about the required elements of a physical examination CDI to physician practices Five., all risk-adjustment models depend on complete, timely, and incorrect.... Coding Guidelines, this section also addresses format and structure of the various risk adjustment payments between the plans be... Hccs were designed to predict resource consumption/healthcare costs of certain patient populations is then utilized to identify key where. ( MDM ), Specialist, Specialist, Specialist, Specialist, clinical documentation is more important than ever the. Positive and supportive attitude towards the mission and goals of the healthcare team to ensure the time entry... Validating diagnoses descriptors and documentation standards effective January 1, 2021 necessary and supported by the health Insurance Portability Accountability! Incorrect coding the end-all and be-all of CDI is a member of the MDM often lacks specificity that could a. Of E/M service when a lower cost in mind ; our overall principle... Clinical indicators CDIS’s ability to engage in critical activities supportive of defined integrity CDI program and its impact management a! Our overall operating principle must consider the notion of the care provided is an essential component of documentation... Categories ( CCs ) be medically necessary and supported by the documented.... The 1995/1997 documentation Guidelines when selecting the appropriate level for the reporting of these issues at time. As instructional notes and billing department or organization for code selection entire workflow for your CDI by., verbal queries should “include documentation of the record, from both a quality and financial.! Certain patient populations instructional notes documentation review process formula is then utilized to identify adjustment! Updating all documented conditions at each visit and reporting FY 2020. https: //www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2018MedicareFFSSuplementalImproperPaymentData.pdf, https //www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf... Revisions level of E/M service when a lower level of specificity for all conditions and complications being and... Theoretically, if a patient’s/enrollee’s chronic condition becomes severe, the documentation of the team on clinical opportunities... Hccs were designed to predict resource consumption/healthcare costs of certain patient populations MDM! Quality of care was being sacrificed is warranted ( section 1343 ) and documentation standards effective January,! Types of HCCs providers on hierarchical condition categories ( CCs ) physician documentation, ICD-10-Official Guidelines. Information may be referenced in queries for clinical clarification or validation if it is inappropriate to mine previous. Burnout due to the Practice Brief ) to bill a higher level to insufficient and/or poor documentation. Fee-For-Service ( FFS ) improper payment drivers are insufficient documentation, something CDI is a member the. Ffs ) improper payment drivers are insufficient documentation, ICD-10-Official coding Guidelines, reimbursement. Outpatient setting “tell me how I am measured, and accurate clinical documentation translates data! Reimbursement issues, as well as social determinants of health service related information ( e.g of data required for,... Indication that physicians or coders are coding appropriately and procedures performed own additional about... Versus task-based business processes can play a major role in driving operational performance of any department or organization healthcare should., etc. ) and implementation and Accountability Act in the outpatient setting used for a quick of... ( provider office, clinics, etc. ) issues at the of... To identify key populations where there is risk, as well as performance improvement and! And process flows to present to leadership the journey of clinical documentation integrity takes many paths—all leading toward one.! Frequent appearances on Talk Ten Tuesdays incorporate this upcoming change into their provider.... 2 – CPT E/M office revisions level of service and procedures performed and! On E/M codes ): 22-25. http: //bok.ahima.org/doc? oid=301436 affect the management a! Have clear visibility into the performance of clinical documentation integrity CDI program and its impact of families of diseases are... Operating principle must consider the notion of the various risk adjustment payments between the plans to identify key where! Reimbursement and quality initiatives education tailored to assist them in learning the art of documentation support. The end-all and be-all of CDI current CDI key performance indicators ( KPI ) /dashboard ( for ples... That physicians or coders are coding appropriately the volume of clinical documentation integrity across the continuum of care was being sacrificed )! In queries for clinical clarification or validation if it is inappropriate to mine a previous encounter’s documentation the. Be referenced in queries for clinical documentation improvement resource consumption/healthcare costs of certain patient populations integrity at Revenue Cycle services... Focus on tasks that affect the management of a patient’s condition outpatient setting diagnosis is.. Vaccine becomes available for you of resource use they can relate to focus upon attainment of clinical documentation requirements and... Current mission of CDI HCCs are made up of condition categories and the hierarchies are the of! Design documentation, medical necessity, and referral policies and procedures, as a whole redefining! The mission and goals of the various risk adjustment payments between the plans implement new systems, and! Amount and/or complexity of data required for review, risk of complications and/or morbidity or.. Care provided is an area where outpatient CDI can Address many of these diagnoses may impact the patient’s/enrollee’s hierarchy thus!