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. This section also addresses format and structure of the classification. A proactive delivery of provider education tailored to assist them in learning the art of documentation integrity will benefit all stakeholders. Depending on the type of practice, such as specialty versus general medicine, E/M level distributions should be compared to national trends. For the data to be meaningful, the documentation of the care provided is an essential component of data analytics. 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. (example: acute systolic CHF, acute bronchitis, CAD with angina, etc.). Number of diagnoses or management options, Amount and/or complexity of data required for review, Risk of complications and/or morbidity or mortality. The concern over this type of reimbursement was that quality of care was being sacrificed. 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. “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. For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring: Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services. CDI supports positive outcomes in patient care, quality, cost, resource consumption, reimbursement, and revenue cycle processes. The education should include examples and/or illustrations of best practices, along with their current documentation practices and areas of improvement. Bonner, Dari and Karen M. Fancher. Eliminating history and physical exam as elements for code selection. 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. While significant to both visit time and medical decision-making, these elements alone should not determine a visit’s code level. 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. Association—delivers best practices in 2018 Medicare Fee-for-service Supplemental Improper Payment Data. These models provide incentives for providers to offer quality care at a lower cost. Follows up on open queries to ensure physician response. 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. Furthermore, telehealth services are increasing in popularity and there are more specific CPT codes that will define the amount of time spent on these services. Facilitate documentation for the reporting of appropriatediagnoses, and procedures, as well as other types of health service related information (e.g. Higher-risk populations consist of patients with chronic conditions that require continuous treatment, monitoring, and maintenance. 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. 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. HCCs were designed to predict resource consumption/healthcare costs of certain patient populations. AMA Table 2 – CPT E/M Office Revisions Level of Medical Decision Making (MDM). Providers are also frequently using checkboxes to meet documentation requirements, especially in the outpatient setting. Current CDI key performance indicators preclude actual achievement of real integrity of the record, from both a quality and financial perspective. Revenue Cycle Management (RCM) can be thought of as the method of transportation to take an organization from one place to where it needs to go. Plans and manages large projects. Makes design and process decisions. “E/M overhaul aims to reduce physicians’ documentation burdens.” American Medical Association. This builds on the movement to better recognize the work involved in non-face-to-face services like care coordination. See Table 3 for an example. American Medical Association (AMA). Providers frequently benefit from tailored education that they can relate to. Additionally, healthcare data can be found in the following: Provider documentation may lack specificity and/or consist of conflicting documentation. 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. Key highlights include: Outpatient (provider office, clinics, etc.). The training program includes: 6 Phases of ICD-10 Training in a LMS (Learning Management System) “Be the Best” Competency Exam All Rights Reserved. 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. Director, Clinical Documentation Integrity. 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. Provides detailed project design documentation, project plans and process flows to present to leadership. Practice Brief: Evolving Roles in Clinical Documentation Integrity: A Provider’s 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. Clinical Documentation Integrity Significance in Revenue Cycle Management Success in Healthcare. Patient presents with a symptom and a definitive diagnosis is made. 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. Attainment of performance measures such as number of charts reviewed and number of queries issued virtually crowds out the CDIS’s ability to engage in actual physician engagement and coaching opportunities that facilitate actual achievement of integrity. 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. Maintains a positive and supportive attitude towards the mission and goals of the provider. 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 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. 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. JOURNAL of AHIMA—the official AMA. Integrity requires, as a whole, redefining the current mission of CDI. Career opportunities abound for CDI specialists who check job board sites and individual healthcare facility websites. and be as accurate as possible in their initial documentation. Anny Pang Yuen, RHIA, CCS, CCDS, CDIP, Approved ICD-10-CM/PCS Trainer, Patty Buttner, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS, CICA, Patricia Maccariella-Hafey, RHIA, CDIP, CCS, CCS-P, CIRCC, Your email address will not be published. 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. 1,878 Clinical Documentation Integrity Specialist jobs available on Indeed.com. The Clinical Documentation Integrity Specialist (CDIS) reviews focus on documentation completeness, accuracy and overall entry detail to facilitate Coding/DRG assignment to best reflect the Severity of Illness, Risk of Mortality, Quality of Care, and the consumption of resources and services rendered to our patient customers. HCCs are made up of condition categories and the hierarchies are the compilation of related condition categories (CCs). 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. Providers need to be aware of the various risk adjustment models and rely on complete, timely, and accurate reporting of patient diagnoses. 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. 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. Provider documentation burden has been debated and addressed by the Centers for Medicare and Medicaid Services, but the need to capture the care of the patient remains. Patient presents at the hospital clinic for examination or testing without a referring diagnosis, symptom, or complaint. 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. 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. Educates members of the team on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement opportunities and methods. 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. A payment transfer formula is then utilized to identify risk adjustment payments between the plans. www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf. The CDI Director will work with all members of the healthcare team to ensure timely and accurate clinical documentation within medical records. Centers for Medicare and Medicaid Services. 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 member’s 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 “HCC” approach was used to create the RxHCC model, The RxHCC model is similar to the Part C CMS-HCC model, Physician engagement in data analytics—they 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. By focusing too closely on reimbursement, we are overlooking the vitally important component of true documentation improvement. 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… 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. 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. The healthcare landscape has changed drastically over the last few months. Develops collaborative relationships and promotes teamwork with co-workers and other departments. American Health Information Management Association (AHIMA). An enrollee can be included in more than one HCC, Each CMS-HCC category is factored into the patient’s/enrollee’s risk profile, which will include acute and/or chronic disease processes along with their manifestations, to capture the patient’s overall risk adjustment factor (RAF) score, The Health and Human Services Hierarchical Condition Categories (HHS-HCC) was developed specifically for the commercial plans, Unlike the CMS-HCC methodology, the HHS-HCC model will calculate a plan’s average risk score for each covered plan based upon the enrollees’ relative risk. Clinical documentation integrity professionals shall: 1.1. 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? 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. 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. 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. Demonstrates knowledge of DRG payer issues, clinical documentation requirements, and referral policies and procedures. Career opportunities abound for CDI specialists who check job board sites and individual healthcare facility websites. present on admission indicators). 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. See Table 4 on for a snapshot of the many different types of HCCs. Glenn is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays. Prior encounter information may be referenced in queries for clinical clarification or validation if it is clinically pertinent to the present encounter. May 4th, 2020 / By Julie Salomon, BSN, RN. Won’t you please join me in an effort to transform CDI to a system that truly makes a difference in patient care, and the saving of our hospitals and our jobs, in this day and age of hospital closures? CDI programs that promote high-quality documentation not only support the capture of appropriate reimbursement but also the quality of care provided to the patient by ensuring all the information within the health record is of high quality … Patient presents with a symptom and no definitive diagnosis is made. 29,190 Clinical Documentation Integrity Jobs. Providers should be encouraged to document the condition being treated by each medication, demonstrating its relevance as a current and reportable condition. This section provides general rules for reporting additional diagnoses. Who Has Rights to a Deceased Patient’s Records? Association of Clinical Documentation Integrity Specialists (ACDIS) This membership association was created especially for CDI professionals that brings together people of … 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 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. The ACA introduced a permanent risk-adjustment program (Section 1343). 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 profession’s ability to achieve CDI from a true “integrity” perspective. These conventions are incorporated within the Alphabetic Index and Tabular List of the ICD-10-CM as instructional notes. See Table 1 for a quick overview of the ICD-10-CM Official Guidelines for Coding and Reporting. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance Portability and Accountability Act in the United States. ), CMS Hierarchical Condition Categories (CMS-HCCs), The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care”, Principal diagnosis is not used in the outpatient setting, instead the term “first-listed diagnosis” is used, In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines, Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” “compatible with,” “consistent with,” or “working diagnosis” or other similar terms indicating uncertainty. Kadlec Renton, WA Type. 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. 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. Clinical documentation integrity in the time of COVID-19. The medication list is also a great resource for CDI professionals who are validating diagnoses. 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. 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. Allowing providers to choose whether their documentation is based on MDM or total time. patient health information. CMS Evaluation and Management Services. 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. … Each contains its own additional details about the required elements of a physical examination. This provision includes revisions to the E/M office visit CPT codes (99201-99215) code descriptors and documentation standards effective January 1, 2021. 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. 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. Streamline Health Clinical Documentation Integrity (CDI) dramatically enhances the entire workflow for your CDI team by automating your concurrent documentation review process. A standard bell curve is not always an indication that physicians or coders are coding appropriately. health information management and Hess, Pamela. See Table 2 for a quick overview of the E/M services. 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By focusing too closely on reimbursement, and accurate clinical documentation integrity at Revenue Cycle business services improvement...: //www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf, https: //www.cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf, https: //www.cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf CDIS’s ability to engage in critical supportive...