Develops collaborative relationships and promotes teamwork with co-workers and other departments. 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? 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. See Table 3 for an example. These additional diagnoses may impact the patientâs 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. Provider documentation must support the history, examination, and medical decision-making (MDM). There are many facets to these models, but one point was clear in the literature, it requires engagement from providers, payers, and patients. Patient presents at the hospital clinic for examination or testing without a referring diagnosis, symptom, or complaint. Clinical documentation tools for value-based care. 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. 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. The three largest improper payment drivers are insufficient documentation, medical necessity, and incorrect coding. CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes. 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. Facilitates and secures accurate clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients. âGuidelines for Achieving a Compliant Query Practice (2019 Update).â http://bok.ahima.org/doc?oid=302674. Clinical documentation integrity (CDI) is a profession that has, in the past, been viewed as just a revenue-seeking programâbut thatâs not the full story. A standard bell curve is not always an indication that physicians or coders are coding appropriately. 1,878 Clinical Documentation Integrity Specialist jobs available on Indeed.com. Clinical Documentation Integrity Significance in Revenue Cycle Management Success in Healthcare. The documentation should always be clear, concise, and to the highest level of specificity so that it paints the most accurate clinical picture. 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. 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. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. Facilitate documentation for the reporting of appropriatediagnoses, and procedures, as well as other types of health service related information (e.g. Streamline Health Clinical Documentation Integrity (CDI) dramatically enhances the entire workflow for your CDI team by automating your concurrent documentation review process. 2019. http://bok.ahima.org/PdfView?oid=302735. 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. Enhanced reimbursement should be thought of and treated as a byproduct of solid documentation reflective of medical necessity for inpatient care, continued hospitalization stay, discharge stability, appropriate resource consumption, and utilization review/management processes under the Conditions of Participation, as well as the quality of care delivery, achieved outcomes, and accurate clinical validation of all assigned ICD-10 codes and DRG assignment. A clinical documentation improvement program is a dedicated team of healthcare professionals that will assure that the medical record documentation reflects an accurate picture of the patient's diagnoses, care provided for those conditions, and the quality of care provided, while the patient is receiving care. Providers who have practiced for years in their own office have been coding their services using charge capture forms or other methods to inform the billing staff of the services provided. 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. November 21, 2019. The accuracy of clinical documentation and reporting of these diagnoses may impact the patientâs/enrolleeâs hierarchy, thus determining reimbursement. In an article published by the American Medical Association (AMA), the key elements of the E/M office visit overhaul include: An opportunity now exists for clinical documentation integrity (CDI) and coding professionals to incorporate this upcoming change into their provider education. However, it is inappropriate to mine a previous encounterâs documentation to generate queries not related to the current encounter. Task-based indicators predicated primarily on the query process preclude the CDISâs ability to engage in critical activities supportive of defined integrity. It is vital to educate all providers on the importance and significance of the integrity of their documentation along with the many reimbursement methodologies and coding guidelines and the changes on the horizon. âExpanding CDI to Physician Practices: Five Documentation Vulnerabilities to Address in 2016.â Journal of AHIMA 87, no. AHIMA. Eliminating history and physical exam as elements for code selection. Patient presents with a symptom and no definitive diagnosis is made. Makes design and process decisions. âE/M overhaul aims to reduce physiciansâ documentation burdens.â American Medical Association. In addition, our CDSs are trained by the AMN Healthcare RCS Director of Education (an AHIMA Ambassador, MHA, RHIT, CCS, ICD-10 Trainer). As the Medicare Claims Processing Manual states, âMedical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. These conventions are incorporated within the Alphabetic Index and Tabular List of the ICD-10-CM as instructional notes. For example, uncertain diagnoses documented as âprobable,â âsuspected,â ârule out,â or other similar terms demonstrating uncertainty can be coded in the inpatient setting but not in the outpatient setting. Often, name changes reflect little substance, and this is no exception. For the data to be meaningful, the documentation of the care provided is an essential component of data analytics. 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. An opportunity now exists for clinical documentation integrity (CDI) and coding professionals to incorporate this upcoming change into their provider education. Maintains a positive and supportive attitude towards the mission and goals of the provider. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2018MedicareFFSSuplementalImproperPaymentData.pdf. 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. 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. 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 traditional fee-for-service model has been declining in popularity by health insurers who have implemented varying types of managed healthcare plans over the years to decrease costs and encourage more efficient delivery of healthcare through risk sharing. Do you have clear visibility into the performance of your CDI program and its impact? Attainment of performance measures such as number of charts reviewed and number of queries issued virtually crowds out the CDISâs ability to engage in actual physician engagement and coaching opportunities that facilitate actual achievement of integrity. 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. While significant to both visit time and medical decision-making, these elements alone should not determine a visitâs code level. Providers should be encouraged to document the condition being treated by each medication, demonstrating its relevance as a current and reportable condition. Providers rely on the 1995/1997 Documentation Guidelines for E/M Services. If the CDI profession is committed to achieving integrity of physician documentation, then it must recognize the immediate, critical need to rebrand the professionâs processes and mission. 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. These models provide incentives for providers to offer quality care at a lower cost. It is important for providers to remember that the selected E/M level must be medically necessary and supported by the documented condition/plan. 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. Director, Clinical Documentation Integrity at Revenue Cycle Business Services . Improvement in diagnosis capture does not equate to clinical documentation excellence, which can be interpreted as the physicianâs ability to become a high-performing communicator of patient care. This section addresses general coding guidelines. 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. While I fully support current CDI initiatives to drive revenue improvement for hospitals facing ongoing revenue cycle headwinds, with payer margin compression and increasing patient financial liability with higher deductibles, this narrowly defined scope of work detracts from the professionâs ability to achieve CDI from a true âintegrityâ perspective. Examinations include general multi-system examination or a single organ system examination. Californian Sentenced to Prison for HIPAA Violation, Watch List: 2021 Privacy and Security Trends, Information Blocking Implementation Roadmap, HIMâs 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. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf. With the use of EHRs in both hospitals and provider practices, ânote bloatâ and the use of cut/copy and paste has caused additional scrutiny on provider documentation. Providers should understand how their clinical documentation translates into data that is used for a variety of purposes. Providers also need to be aware that their documentation is captured through many types of coded data including, but not limited to, ICD-10-CM/PCS, CPT, RxNORM, SNOMED CT, and Logical Observation Identifiers Names and Codes (LOINC). Clinical Documentation Integrity Training. 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 âabnormal,â ânegative,â and ânormal.â. Guide and support projects, process, implementation and training teams. 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. Providers are also frequently using checkboxes to meet documentation requirements, especially in the outpatient setting. 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. 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 memberâs 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 âHCCâ approach was used to create the RxHCC model, The RxHCC model is similar to the Part C CMS-HCC model, Physician engagement in data analyticsâthey 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. To think that queries and increased case mix index (CMI) is the end-all and be-all of CDI is a fallacy. Required fields are marked *, Â© Copyright AHIMA 2020. 5 (May 2016): 22-25. http://bok.ahima.org/doc?oid=301436. 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.â Provider response to the query must be documented in the permanent health record in order to be coded. This may go beyond the realm of the typical CDI professionalâs role, but the documentation of the diagnosis and procedures performed is just as important. 2018 Medicare Fee-for-service Supplemental Improper Payment Data. AMA Table 2 â CPT E/M Office Revisions Level of Medical Decision Making (MDM). Practice Brief: Evolving Roles in Clinical Documentation Integrity: A Providerâs 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. 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. We must respect the medical record with the patient in mind; our overall operating principle must consider the notion of the patient. CMS Evaluation and Management Services. So why is it important for the providers to report additional diagnoses even though they are not going to link to a service (CPT code) line? However, the documentation of the MDM often lacks specificity that could support a higher level. Copyright Â© 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. American Health Information Management Association (AHIMA). 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. (example: acute systolic CHF, acute bronchitis, CAD with angina, etc.). Professionals performing the query function should maintain a compliant query process. 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. patient health information. Designed for the experienced coders or audtiors, AAPC's CDEO online training course covers the benefits of clinical documentation improvement (CDI) programs, documentation requirements, quality measures, payment methodologies, and clinical conditions including common signs and symptoms, typical treatment, documentation tips and coding concepts. These guidelines assist providers in determining the most appropriate level of service to bill for their E/M services by providing guidance on what elements need to be included in their documentation. This is an area where outpatient CDI can be of great value. 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. Many larger facilities encourage providers to code their levels of service and procedures performed. 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. American Medical Association (AMA). Funds will be transferred from plans with relatively low risk enrollees to plans with relatively high-risk enrollees, The HHS-HCC risk adjustment model addresses the following: (1) newly insured population; (2) plan metal level differences and rating variation; and (3) the need for risk adjustment transfers that net to zero, Concurrent risk adjustment models are established in the HHS-HCC methodology, consisting of age groups (e.g. 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. Depending on the type of practice, such as specialty versus general medicine, E/M level distributions should be compared to national trends. See Table 1 for a quick overview of the ICD-10-CM Official Guidelines for Coding and Reporting. Number of diagnoses or management options, Amount and/or complexity of data required for review, Risk of complications and/or morbidity or mortality. Risk adjustment methodologies assign families of diseases to a cost based on severity and projected use of resources. 29,190 Clinical Documentation Integrity Jobs. 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 â¦ Assists in educating physicians regarding documentation to the highest level of specificity for all conditions and complications being addressed and treated. Contain clinical indicators from the health record, Present only the facts identifying why the clarification is required, Be compliant with the practices outlined in this Practice Brief, Never include impact on reimbursement or quality measures, Do not lead the provider to a certain diagnosis, Include appropriate clinical indicators to support the query. 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. A CDI professional can also be a valuable part of an analytics team. Documentation should support the level of service reported.â, Claim edits and correct coding initiatives. Integrity requires, as a whole, redefining the current mission of CDI. The concern over this type of reimbursement was that quality of care was being sacrificed. It has never been more important to engage up front with clinicians and help CDI teams close the loop between clinical care and revenue integrityâall without increasing administrative burdens. CMS. 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. Higher-risk populations consist of patients with chronic conditions that require continuous treatment, monitoring, and maintenance. 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. Current CDI key performance indicators preclude actual achievement of real integrity of the record, from both a quality and financial perspective. 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. â¦ 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. Clinical Documentation Integrity (CDI) Specialist Salt Lake City, Salt Lake is the capital and most populous city in Utah. This section also addresses format and structure of the classification. The journey of clinical documentation integrity takes many pathsâall leading toward one goal. www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf. 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?
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