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

Getting their Money’s Worth…Value-Based Purchasing

Value-based purchasing further emphasizes the ripple effect and spider web of CDI, HIM and Quality. Everyone “knows” about value-based purchasing, but what is it comprised of?

Value-based purchasing (VBP) is both a broad and narrow quality measurement tool. Broadly defined, pay for performance (P4P)/ VBP is payer-developed metrics to measure value compared to reimbursement given. Two examples are accountable care organizations (ACOs) and bundled payments. A narrow definition is a program mandated by the Affordable Care Act of 2010 and administered by CMS. VBP has been in development for almost 10 years but was formally introduced for FY 2013. Through the Medicare program, incentive payments are made to hospitals based on either how well they perform or improve against their own baseline on each domain comprising VBP. There are four domains: clinical process of care, patient experience of care, outcome (FY 2014 forward) and efficiency (FY 2015 forward). Each domain is assigned an associated weight. For example, in FY 2015 clinical process is 20 percent of the total VBP score, patient experience is 30 percent, outcome is weighted at 30 percent and efficiency rounds it out at 20 percent. Continue reading

Will 2014 be a Year to Remember for Outpatient CDI?

The other day, I was thinking back to the year 1987: Ronald Reagan was President, the New York Giants won the Super Bowl and the Minnesota Twins won the World Series. Michael Jackson released his third album, Bad, and “Walk Like an Egyptian” by the Bangles was the number one hit on The Billboard Top 100.

1987 was also the beginning of an important initiative in healthcare and health information management. This was the year that 3M created its inpatient clinical documentation improvement (CDI) program. Continue reading

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