CMS. CDI will be achieved through an unrelenting focus upon attainment of clinical documentation excellence. In the outpatient setting, providers are reimbursed for their professional services based on E/M codes. Conversations should be non-leading, include all appropriate clinical indicators, and include all plausible options. This provision was finalized in response to provider burnout due to the administrative burden related to documentation requirements. 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. 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. This is an area where outpatient CDI can be of great value. November 21, 2019. Clinical documentation integrity (CDI) programs are highly ingrained in most hospital and healthcare facilities. November 1, 2019. https://www.ama-assn.org/practice-management/cpt/em-overhaul-aims-reduce-physicians-documentation-burdens. 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. 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.) 2018 Medicare Fee-for-service Supplemental Improper Payment Data. (example: acute systolic CHF, acute bronchitis, CAD with angina, etc.). Kadlec Renton, WA Type. The training program includes: 6 Phases of ICD-10 Training in a LMS (Learning Management System) “Be the Best” Competency Exam It’s important to identify key populations where there is risk, as well as social determinants of health for specific populations. The term value-based care encompasses models such as risk sharing (capitation) with quality incentives, accountable care, population health, and bundled payments. Outpatient CDI Programs: Are They Poised for Effectiveness and Success? ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance Portability and Accountability Act in the United States. The accuracy of clinical documentation and reporting of these diagnoses may impact the patient’s/enrollee’s hierarchy, thus determining reimbursement. 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. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf. 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. Therefore, providers need to be educated on how to appropriately select the most accurate diagnosis and to not select codes based on the first diagnosis that pops up and/or is identified as an HCC. … https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/2018MedicareFFSSuplementalImproperPaymentData.pdf. www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf. CDI supports positive outcomes in patient care, quality, cost, resource consumption, reimbursement, and revenue cycle processes. 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. Care coordination/population health data. Full-Time. timeliness, privacy, and security of 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. See Table 2 for a quick overview of the E/M services. Healthcare organizations should leverage their coding and CDI professionals to provide this type of provider education. keeps readers current on emerging According to the AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice (2019 Update), all queries, including verbal queries, should be documented in writing to demonstrate compliance with all query requirements to validate the essence of the query. 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, … 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. 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. Risk adjustment methodologies assign families of diseases to a cost based on severity and projected use of resources. 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. “Expanding CDI to Physician Practices: Five Documentation Vulnerabilities to Address in 2016.” Journal of AHIMA 87, no. 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. Clinical Documentation Integrity (CDI) Specialist Salt Lake City, Salt Lake is the capital and most populous city in Utah. 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. 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. 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. 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. To think that queries and increased case mix index (CMI) is the end-all and be-all of CDI is a fallacy. Additionally, healthcare data can be found in the following: Provider documentation may lack specificity and/or consist of conflicting documentation. See Table 4 on for a snapshot of the many different types of HCCs. Often, name changes reflect little substance, and this is no exception. Guide and support projects, process, implementation and training teams. A payment transfer formula is then utilized to identify risk adjustment payments between the plans. 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. Without medical necessity, there simply is no CDI, regardless of how you look at it. The definitive diagnosis is reported, symptoms integral to a definitive diagnosis are not reported. 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. Providers can use either 1995 or 1997 documentation guidelines when selecting the appropriate level for the patient visit. Allowing providers to choose whether their documentation is based on MDM or total time. 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. JOURNAL of AHIMA—the official The three largest improper payment drivers are insufficient documentation, medical necessity, and incorrect coding. Streamline Health Clinical Documentation Integrity (CDI) dramatically enhances the entire workflow for your CDI team by automating your concurrent documentation review process. The Clinical Documentation Integrity (CDI) Manager reports to a Director within a specific division of the organization…The manager has overall responsibility for the daily planning, work scheduling and coordination, and operational performance of the defined Clinical Documentation Improvement program… There are numerous opportunities now to extract data out of the EHR. COVID-19 Coding Dilemma: Z20.828 and Z03.818, Screening for COVID-19: When to use Z11.59, CMS Issues Interim Final Rule Establishing New COVID Treatment Add-On Payment, Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, Evan M. Gwilliam, DC, MBA, BS, CPC, CCPC, CCCPC, NCICS, CPC-I MCS-P, CPMA, Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer, Kim Carr, RHIT, CCS, CDIP, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer, Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer, Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer, Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, COPC, CPEDC, CGSC, Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer, Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC, Wilbur Lo, MD, CDIP, CCA, AHIMA-Approved ICD-10-CM/PCS Trainer. The medical record content is all about the patient. HCCs were designed to predict resource consumption/healthcare costs of certain patient populations. 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. The symptom is reported (example: shortness of breath, cough, chest pain, etc.). May 4th, 2020 / By Julie Salomon, BSN, RN. Clinical Documentation Integrity Training. ACDIS members save $150 off the registration fee. 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? The concern over this type of reimbursement was that quality of care was being sacrificed. present on admission indicators). Professionals performing the query function should maintain a compliant query process. Role-Based Versus Task-Based Clinical Documentation Integrity: A Major Determinant of Operational Performance The CDI profession has failed to effectively articulate its value in the revenue cycle. Director, Clinical Documentation Integrity at Revenue Cycle Business Services . 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. “E/M overhaul aims to reduce physicians’ documentation burdens.” American Medical Association. 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. and administrative support team members regarding the clinical documentation requirements. CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes. 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? Providers should understand how their clinical documentation translates into data that is used for a variety of purposes. Hospital clinic reports an encounter code that accurately reflects the reason for the encounter (Example: Z00.00; Encounter for general adult medical examination without abnormal findings, Z00.01; Encounter for general adult medical examination with abnormal findings, etc. The rule of thumb is for providers to report a complete list of diagnoses that captures all the conditions that warranted the outpatient services. The healthcare landscape has changed drastically over the last few months. CLINICAL DOCUMENTATION INTEGRITY SPEC- AMBULATORY. 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