Clinical Documentation Improvement

Clinical Documentation Improvement

CDI - Clinical Documentation Improvement

CDI - Clinical Documentation Improvement
Dr. Jake Martin, a long time physician documentation champion whose passion is working with physicians to teach a better way to documenting and communicating patient care in the electronic health record, discusses his thoughts on how the CDI profession can shore up physician documentation, strengthen physician documentation. Where should CDI be focusing their efforts to reduce costly self-inflicted denials that are generated through the query process. Dr. Martin discusses how the current Key Performance Indicators of today detract from the professions’ ability to drive real meaningful measurable sustainable improvement in documentation. He also outlines what KPIs are more appropriate that will support CDI’s efforts in working with physicians to achieve true documentation integrity that stands the test of time. Ben Kartchner, MD, Member Board of Directors American College of Physician Advisors/Regional Associate Medical Director Care Management at MultiCare Health System, continues to practice as a hospitalist part-time. Dr. Kartchner is Physician Advisor for the health system’s Clinical Documentation Improvement Program at several hospitals. His vision of CDI goes well beyond the traditional query process that contributes to physician burnout and more self-inflicted payer denials. Dr Kartchner shares his ideas and thoughts on a “Better Way to CDI” in this episode, comparing present CDI processes that are reactive, episodic, transactional and repetitive to a far more efficient model of CDI that treats the medical record as a communication tool versus a reimbursement tool. A better Way to CDI requires a commitment by the profession to total transformation of present day processes to one that embraces a holistic approach to chart review, working with physicians, physician advisors, Case Managers, Utilization Review/Utilization Management and Denials and Appeals. Dr. Katchner provides an outline for all CDI programs to follow in jumpstarting the transformative journey to a Better Way to CDI.
CDI Intelligence - Capitalizing Upon the Opportunity - Dr. Ben Kartchner
Traditional CDI approaches that rely on the proverbial query process generate more payer denials, do not educate and teach physicians on better practices of documentation, and certainly fail to change overall physician documentation patterns for the better, CDI must evolve and transform itself from one of reactive repetitive transactional task based activities to one that embraces the major role CDI plays in helping physicians master best practice standards and principles of documentation. Dr. Martin shares his thoughts and vision of CDI in its next phase, adopting strategies to focus upon documentation processes that best communicate physician workup and care of the patient while aligning with the goals of a high performing revenue cycle. Payers are winning when it comes to denials with many of these providers self-inflicted. The CDI profession can capitalize upon the opportunity to work with physicians as facilitators and guides to achieving clinical documentation excellence.
CDI Intelligence - Going Beyond the Traditional Approach to CDI - Jake Martin, MD
Join Kyle Boyd, RN, CCDs on The Clinical Documentation Intelligence Podcast, aka a podcast for "The CDI", where Kyle shares his passion and thoughts on how CDI can work together to change the "Clinical Revenue Cycle for the Better." The revenue cycle is siloed with each component of the revenue cycle not communicating and working towards the common goal of quality focused patient centered fully informed coordinated care supporting an optimally performing revenue cycle. Kyle discusses the role of CDI in breaking down silos, serving as the torch bearer and change agent for jumping start a more highly efficient revenue cycle, thinking outside the box when it comes to transforming CDI to a more proactive approach to improving physician documentation. CDI specialists are handicapped to some extent in broadening their breadth and depth of contribution to achieving sustainable true measurable meaningful improvement in physician documentation, attributable to the traditional CDI KPIs that do not actually correlate with real physician documentation integrity. Kyle provides his ideas on how the CDI profession can convince and make a compelling case for CFOs and other Revenue Cycle professionals to expand their knowledge and understanding of CDI, allowing the profession the latitude and direction to branch out, reinvigorate and reinvent CDI processes to drive real documentation integrity beyond the current narrow scope of CDI as it exists today. Current CDI efforts have not produced real change in physician documentation patterns due to constraints beyond our control and expectations that narrowly define our present chart review process.
CDI Intelligence - A Physician's Perspective - Kyle Boyd (RN, CCDS)
Mark Johnson PAC (MPAS), a Physician Assistant with almost two decades of experience, is the featured guest on the Clinical Documentation Intelligence Podcast today. He is passionate about provider documentation and discusses the common documentation challenges faced by all medical practitioners. One of the major causes of burnout among providers is the electronic health record, which demands that providers spend at least two hours away from patient care to document in the EHR. Mark shares his strategies for streamlining his documentation process, reducing the time he spends working on the computer, and dedicating more time to caring for patients. He also offers his insights into what providers expect from the Clinical Documentation Integrity profession, including practical educational training on how to improve documentation, the importance of working smarter, not harder, while charting in the EHR, and the need for regular constructive feedback, rather than additional queries, to enhance their documentation skills.
CDI Intelligence - A Physician's Perspective - Mark Johnson PAC(MPAS)
Hear from a physician third year resident the preferred makeup of a physician documentation educational training program beginning with residency on day one. Residency is the best time to provide documentation educational training. The CDI profession plays a vital role in developing and implementing a multidisciplinary approach to effective ongoing physician documentation training that includes immediate feedback and ongoing mentoring. CDI can think of themselves as Mentors, Facilitators, and Guides to physicians in their quest to achieve true physician documentation integrity and excellence
CDI Intelligence - A Physician's Perspective - Dr. Daniel Aragon
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AE & Associates offers the following revenue cycle consulting services:

Education, Training, and Knowledge Sharing 

  • Provide ongoing physician clinical documentation education, training, and knowledge sharing on best practice principles and standards of documentation.

  • Provide training, education, and knowledge sharing in E & M assignments with a specific focus upon communication of fully informed coordinated care.

  • Conduct ongoing assessment of the quality and completeness of physician documentation through the use of a valid and reliable clinical documentation scorecard.

  • Tailor and implement clinical coding education and training to coding staff utilizing up-to-date official ICD-10 and CPT coding guidelines, policies, and procedures.

Clinical Documentation Improvement

  • Assessment of hospital’s current CDI initiatives using a blended approach of traditional and nontraditional methodologies for purposes of gaining an accurate true picture of the effectiveness of the established CDI program.

  • Training and mentoring of new and experienced CDI professionals incorporating a holistic approach to chart review and documentation improvement that puts the patient at the center of communication.

  • Conduct regular offsite second-level reviews of CDI previously reviewed medical records for purposes of validating accuracy.

Clinical Coding Assessment

  • Conduct a clinical coding review of professional and facility records providing an assessment of overall clinical coding accuracy incorporating elements of the adequacy of clinical documentation and potential risks of medical necessity denials, clinical validation denials, and DRG down-codes.

  • Provide the client with a detailed report of findings with the inclusion of a Management Action Plan outlining actionable items to address any identified process concerns including but not limited to documentation insufficiencies and inadequate coding.

Observation Rate Review & Analysis  

  • A detailed and expert review of Observation cases to assess clinical appropriateness of “observation level of care” using all the available information in the medical record. The assessment consists of a thorough review of 100 observation cases to decide whether the patients were appropriately placed in observation.

  • The report and Executive Summary includes Quantifiable results with Management Action Plan and clear recommendations and next steps to compliantly achieve the proper Observation Rate for your Hospital.

Chargemaster Reviews

  • Conducting of thorough chargemaster review identifying and addressing any inconsistences, problematic areas, and other issues.

  • Restructure chargemaster as needed to bring all charge codes within cost-justified transparency.

  • Updating all elements of the chargemaster as needed with specialized focus and emphasis upon educating and training department staff who utilize the chargemaster to understand and properly use the appropriate charge codes within their department, recognizing that a chargemaster is a form of code assignment tool.

Denial/Appeal Assessment & Modernization

  • Assessment of current hospital and/or physician practice denials and appeals processes, identifying and determining limiting factors contributing to inefficiencies and inability to effectively overturn appeals.

  • Focus upon identifying and determining root cause analysis with development and implementation of process improvement strategies farther up the revenue cycle that alleviate and minimize denials in the first place.

  • Transform denials management to denials avoidance through the initiation of cultural changes within the organization, emotionally connecting physicians and other healthcare stakeholders with their patients.