Category Archives: Clinical Documentation Improvement

Concurrent Documentation Review; CDI; concurrent chart review; complications and comorbidities; MCCs; Co-morbidities; Severity of Illness; SOI; Risk of Mortality; ROM; documentation at the point of care; MS-DRGs; Medicare Severity DRGs; APR-DRGs; casemix; case mix index; CMI; risk adjustment; chart completion

Medical Necessity Documentation – the Critical Component for CAC

Whether or not you can quote chapter and verse of the Medicare statute that first detailed medical necessity, most of us in healthcare are familiar with its premise1. But from this basic tenant we begin to diverge widely in our understanding of the concept. This is especially true for Medicare inpatient services since CMS does not have specific standards the industry can follow. This issue dates back to the late 1980s when then HCFA admitted, “Current regulations are general and we have not defined the terms ‘reasonable’ and ‘necessary’ nor have we described in regulations a process for how these terms must be applied…”2 Continue reading

CDI and Document Creation: Aligning Goals and Processes

Last week I attended my first CDI Summit. As a specialist in the document creation process, I knew that I was going into the conference with a different perspective on healthcare documentation than most attendees, but I was hoping to see how the goals and processes of clinical documentation improvement (CDI) align with the goals and processes of documentation capture and quality assurance.

I was happy that all of the sessions I attended related in some way to how the documentation is being captured in health care, either through traditional dictation and transcription, speech recognition, templates, or direct data entry. On several occasions I heard the CDI mantra, “If it isn’t documented, it didn’t happen,” because the focus of CDI is on attaining accurate and timely documentation that reflects the scope of services provided to the patient. Continue reading

“Documentation is the beginning….not the end”

I wish I could claim this quote as my own! I attended the AHIMA CDI Summit in Washington, D.C. this week and our keynote speaker was Laura Zubulake. My two takeaways from her presentation were the quote above and the affirmation that we should always do the right thing…not the easy thing.

One of the more interesting presentations of the week was from a cardiologist who provided insights into the CDI and HIM query process from his perspective. He had an excellent grasp of what was needed for accurate coding–until that one moment. I am sure many of us have been there: listening to a presentation, engaged and learning until we hear something that makes us cringe. He described the following scenario: Continue reading

Attitude + Commitment = Excellence at the AHDI Conference

Last week I attended the Association for Healthcare Documentation Integrity (AHDI) conference in Las Vegas, Nevada. This time around I was honored to serve as president, which meant I had the privilege of introducing keynote speaker Ronald Wyatt, MD, the Medical Director within the Division of Healthcare Improvement at The Joint Commission. He kicked off the conference by encouraging the medical transcriptionists and other healthcare documentation specialists to continue supporting clinicians in capturing and editing documentation so that quality is improved and errors are eliminated. He advocated for patient care documentation that is highly accurate, complete and reliable, and asked attendees to do all that they could to build an environment in which a zero error rate (and zero patient harm) is the expectation. Continue reading

Oh what a tangled web we weave…The impact of CDI and Coding part II

I previously discussed how selection of principal diagnosis may impact quality. This ripple effect (like a pebble on a pond) may occur when one works in a silo, ignoring other departments such as quality. If only the ripple effect was the lone “offender” in which CDI and coding may impact quality outcomes. Consider a spider web: intricately designed and seeming impervious. However, as strands get broken, the web collapses.

In review, CDI professionals and coders are tasked with obtaining and capturing a complete picture of the patient’s encounter for appropriate reimbursement, accurate reflection of severity of illness (SOI) and risk of mortality (ROM) and outcomes of care. Historical models of CDI programs and coding processes focused predominately on the first two tasks, without acknowledgement of how this may affect quality outcomes (potentially fracturing the spider web). Continue reading

Toss Those Pebbles Carefully…The Ripple Effect of CDI and Coding on Quality Outcomes

I have never been able to skip a stone, but I do enjoy watching the ripples expand until they disappear. Or do they?

Clinical documentation improvement (CDI) has been around for quite a while and the function has changed throughout the years. Initially, the focus was on appropriate financial reimbursement for resources provided to patients. As quality of care became more transparent, the scope expanded into accurate reflection of severity of illness and risk of mortality. Today, the role of clinical documentation has grown far beyond these two functions. Continue reading

Quality Reviews: Delivering Constructive Feedback

To many healthcare documentation specialists (HDS), the QA process can feel like being scored for an academic grade. This is because a medical transcriptionist’s performance review, and sometimes even their compensation, is affected by her quality scores. But as I have discussed in previous posts, quality in documentation is a team sport in which the dictator, HDS, QA reviewer, and final authenticator(s) are all expected to contribute their best efforts to the document. Although it is important to ensure that each individual is doing her part to generate complete and accurate documentation, quality reviews should be treated as an opportunity to provide education and feedback toward continuous quality improvement. Continue reading

National Medical Transcription Week: It’s time we thank the guardians of health record integrity

This week is National Medical Transcription Week, and I would like to thank all of the hardworking medical transcriptionists and other healthcare documentation specialists (HDS) who support physicians every day in creating complete, accurate, and high quality patient care documentation. This year’s theme is “Guardians of Health Record Integrity;” so I would like to highlight a very important but often overlooked part of the healthcare documentation process, quality assessment (QA).

Within the healthcare documentation process, there are three different workflows for QA: Continue reading

Listen up: How the healthcare documentation team can optimize quality

In my February post, “Can You Hear Me Now?” I shared a list of suggestions for physicians and other dictators to help improve documentation quality. This time around, I am going to focus on the healthcare documentation staff in HIM and transcription. There are many best practices that the healthcare documentation team can implement to assist with dictation and documentation quality, and they all fit into three major categories:

Set expectations

The best way to get the results you want is to spell out what you expect through standards, procedures, and best practices. The healthcare documentation team needs to set the tone for how the organization captures patient information by: Continue reading

ONC Leaders on Ensuring Data Quality

On February 26 I was fortunate to attend a summit on “The Decade of Health IT” at the HIMSS 14 conference in Orlando, FL. The summit was sponsored by the Certification Commission for Health Information Technology (CCHIT) and featured a panel discussion made up of the current and three former National Coordinators for Health Information Technology. As part of the dialogue, audience members were invited to tweet questions for the panel concerning the future of HIT. I asked a question concerning data quality and want to share the response with you.

This was my initial question:Jill Devrick, Tweet 1

It generated a discussion among the panelists, which I recorded. Here’s how the panel conversation played out: Continue reading