This provision includes revisions to the E/M office visit CPT codes (99201-99215) code descriptors and documentation standards effective January 1, 2021. 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. Streamline Health Clinical Documentation Integrity (CDI) dramatically enhances the entire workflow for your CDI team by automating your concurrent documentation review process. CMS Evaluation and Management Services. publication of the American Health It is important for providers to remember that the selected E/M level must be medically necessary and supported by the documented condition/plan. 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. The healthcare landscape has changed drastically over the last few months. These models provide incentives for providers to offer quality care at a lower cost. Clinical documentation integrity (CDI) programs are highly ingrained in most hospital and healthcare facilities. Bonner, Dari and Karen M. Fancher. 2018 Medicare Fee-for-service Supplemental Improper Payment Data. For example: Section I.C: Chapter-Specific Coding Guidelines, This section addresses guidelines related to chapter-specific diagnoses and/or conditions. ICD-10-CM Official Guidelines for Coding and Reporting contains separate guidelines for inpatient and outpatient settings. Follows up on open queries to ensure physician response. See Table 4 on for a snapshot of the many different types of HCCs. “Guidelines for Achieving a Compliant Query Practice (2019 Update).” http://bok.ahima.org/doc?oid=302674. Examinations include general multi-system examination or a single organ system examination. This is an area where outpatient CDI can be of great value. If the CDI profession is committed to achieving integrity of physician documentation, then it must recognize the immediate, critical need to rebrand the profession’s processes and mission. Achieving optimal performance across the continuum. AHIMA. 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. 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. 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. Develops collaborative relationships and promotes teamwork with co-workers and other departments. 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. A proactive delivery of provider education tailored to assist them in learning the art of documentation integrity will benefit all stakeholders. 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. Assists in educating physicians regarding documentation to the highest level of specificity for all conditions and complications being addressed and treated. Each contains its own additional details about the required elements of a physical examination. 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. Documentation should support the level of service reported.”, Claim edits and correct coding initiatives. 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. Queries, whether performed verbally, by paper, or electronically, serve the purpose of supporting clear and consistent documentation of diagnoses during a patient’s visit. 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. AMA Table 2 – CPT E/M Office Revisions Level of Medical Decision Making (MDM). 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. 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. 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. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Coordinates resources to implement new systems, programs and processes within the department. By focusing too closely on reimbursement, we are overlooking the vitally important component of true documentation improvement. American Health Information Management Association (AHIMA). Furthermore, many providers are being queried for additional clarifications that may or may not be appropriate, causing additional documentation discrepancies within a health record. This section addresses general coding guidelines. Clinical documentation tools for value-based care. For example, if a patient came in for an office visit for a cough and during the examination the provider documented that the patient is also treated with medication for diabetes and hypertension and has a history of right leg amputation status following a motor vehicle accident. CLINICAL DOCUMENTATION INTEGRITY MANAGER. A CDI professional can also be a valuable part of an analytics team. 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. Association of Clinical Documentation Integrity Specialists (ACDIS) This membership association was created especially for CDI professionals that brings together people of … Hess, Pamela. See Table 3 for an example. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf. 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. Clinical documentation integrity (CDI) is a profession that has, in the past, been viewed as just a revenue-seeking program—but that’s not the full story. A standard bell curve is not always an indication that physicians or coders are coding appropriately. 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. Kadlec Renton, WA Type. 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 Providers should understand how their clinical documentation translates into data that is used for a variety of purposes. 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. Providers need to be aware of the various risk adjustment models and rely on complete, timely, and accurate reporting of patient diagnoses. 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. (example: acute systolic CHF, acute bronchitis, CAD with angina, etc.). Can your clinical documentation integrity (CDI) teams prioritize work for scalability? A payment transfer formula is then utilized to identify risk adjustment payments between the plans. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance Portability and Accountability Act in the United States. Well-established program: Brought to you by the Association of Clinical Documentation Integrity Specialists (ACDIS), this Boot Camp from the industry’s only dedicated CDI association provides the best-in-class education you expect. 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. Centers for Disease Control and Prevention. 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. 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. Check job board sites and individual healthcare facility websites director and more programs and processes within the department of! For the clinical documentation integrity to be aware of the team on clinical documentation to ensure time. 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