Role-based versus task-based business processes can play a major role in driving operational performance of any department or organization. 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. The three pillars of clinical documentation excellence are the following: Clinical Documentation Integrity: Repurposing and RebrandingConsidering all the medical necessity and clinical validation denials seen across the industry of late, as well as DRG and level-of-care downgrades from payers, clearly, the CDI profession is not achieving clinical documentation integrity in the strictest sense of the words. Care coordination/population health data. 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. To think that present-day CDI efforts are benefiting the patient, the physician, all healthcare stakeholders, and the achievement of a high-performing revenue cycle is a fallacy. Without medical necessity, there simply is no CDI, regardless of how you look at it. In the outpatient setting, providers are reimbursed for their professional services based on E/M codes. 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. 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. We meet you wherever you are in your CDI journey with solutions that include encounter prioritization, workflow, analytics, and services that can be packaged to take your program further. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2018MedicareFFSSuplementalImproperPaymentData.pdf. The CDI Director will work with all members of the healthcare team to ensure timely and accurate clinical documentation within medical records. 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. As already mentioned, accurate and precise provider documentation is more important than ever in the changing landscape of provider reimbursement and quality initiatives. Documentation should support the level of service reported.”, Claim edits and correct coding initiatives. Providers are also frequently using checkboxes to meet documentation requirements, especially in the outpatient setting. This section provides general rules for reporting additional diagnoses. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf. 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. Barnette, Erin et al. Documentation should also be reviewed and validated at the time of entry. 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. 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. Do you have clear visibility into the performance of your CDI program and its impact? (example: acute systolic CHF, acute bronchitis, CAD with angina, etc.). 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. Apply to Document Specialist, Specialist, Clinical Director and more! AMA Table 2 – CPT E/M Office Revisions Level of Medical Decision Making (MDM). Validates DRG assignment with medical record documentation, ICD-10-Official Coding Guidelines, and supporting clinical indicators. 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. To think that queries and increased case mix index (CMI) is the end-all and be-all of CDI is a fallacy. Clinical & Coding, News, Policies & Procedures This month, CMS begins auditing a sample of hospitals for compliance with price transparency rule. It is important for providers to remember that the selected E/M level must be medically necessary and supported by the documented condition/plan. 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. Each contains its own additional details about the required elements of a physical examination. American Medical Association (AMA). However, they cannot use both guidelines. Who Has Rights to a Deceased Patient’s Records? The concern over this type of reimbursement was that quality of care was being sacrificed. The education should include examples and/or illustrations of best practices, along with their current documentation practices and areas of improvement. The three largest improper payment drivers are insufficient documentation, medical necessity, and incorrect coding. The healthcare landscape has changed drastically over the last few months. Most medical necessity denials are attributable to insufficient and/or poor physician documentation, something CDI is not currently addressing through the query process. CCDS certification starts here. 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. Examinations include general multi-system examination or a single organ system examination. 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. 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. present on admission indicators). 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. Director, Clinical Documentation Integrity at Revenue Cycle Business Services . Also important are chronic conditions—what are the most frequently documented conditions, and does documentation exist to show the conditions were addressed during a visit? 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. “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. 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? 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. A payment transfer formula is then utilized to identify risk adjustment payments between the plans. JOURNAL of AHIMA—the official 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. Educates members of the team on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement opportunities and methods. “E/M overhaul aims to reduce physicians’ documentation burdens.” American Medical Association. Risk adjustment methodology for the Medicare Advantage patient population (Medicare Part C), Reflects hierarchies among related disease categories, Not all diagnoses will map to an HCC or “risk adjust”, Higher categories/risk scores represent higher predicted healthcare costs. As mentioned above, all risk-adjustment models depend on complete and accurate reporting of patient data. This section provides coding guidelines for outpatient diagnoses used by hospitals/ providers in coding and reporting hospital-based outpatient services and provider-based office visits. 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. CDI supports positive outcomes in patient care, quality, cost, resource consumption, reimbursement, and revenue cycle processes. Providers need to be aware of the various risk adjustment models and rely on complete, timely, and accurate reporting of patient diagnoses. 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. CDI Practice Has Evolved, but our Metrics Haven’t: Why Is CDI Different from Other Departments? An area where outpatient CDI programs: are they Poised for Effectiveness and Success coding professionals to incorporate this change. Guidelines, this section provides coding Guidelines, this section also addresses format and structure of the various adjustment. 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