Requisition Number: 10960 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, including Duke University … https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf. Conversations should be non-leading, include all appropriate clinical indicators, and include all plausible options. (example: acute systolic CHF, acute bronchitis, CAD with angina, etc.). Bullet points are the key component used to determine the type of examination. 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. All Rights Reserved. The hierarchy consists of families of diseases that are assigned a cost based on severity of illness and projection of resource use. 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. 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. 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. 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. health information management and There are many facets to these models, but one point was clear in the literature, it requires engagement from providers, payers, and patients. 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. These models provide incentives for providers to offer quality care at a lower cost. timeliness, privacy, and security of adult, child, infant) and level of metal (e.g. Examinations include general multi-system examination or a single organ system examination. 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. Director, Clinical Documentation is responsible for the Clinical Documentation Integrity (CDI) across all Memorial Hermann hospitals. Career opportunities abound for CDI specialists who check job board sites and individual healthcare facility websites. American Health Information Management Association (AHIMA). Funds will be transferred from plans with relatively low risk enrollees to plans with relatively high-risk enrollees, The HHS-HCC risk adjustment model addresses the following: (1) newly insured population; (2) plan metal level differences and rating variation; and (3) the need for risk adjustment transfers that net to zero, Concurrent risk adjustment models are established in the HHS-HCC methodology, consisting of age groups (e.g. AMA Table 2 – CPT E/M Office Revisions Level of Medical Decision Making (MDM). The term value-based care encompasses models such as risk sharing (capitation) with quality incentives, accountable care, population health, and bundled payments. “Guidelines for Achieving a Compliant Query Practice (2019 Update).” http://bok.ahima.org/doc?oid=302674. To think that queries and increased case mix index (CMI) is the end-all and be-all of CDI is a fallacy. Plans and manages large projects. See Table 3 for an example. Furthermore, many providers are being queried for additional clarifications that may or may not be appropriate, causing additional documentation discrepancies within a health record. Fran Jurcak, Chief Clinical Strategiest at Iodine Software with over 30 years of success in healthcare practice, education, consulting and technology shares thoughts on the impact of COVID-19 on clinical documentation integrity. Clinical documentation integrity (CDI) programs are highly ingrained in most hospital and healthcare facilities. Documentation should also be reviewed and validated at the time of entry. However, it is inappropriate to mine a previous encounter’s documentation to generate queries not related to the current encounter. 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. The new paradigm of CDI may be defined as the completeness, consistency, organization, and accuracy of the medical record, reflecting the physician’s clinical judgment and medical decision-making. Outpatient CDI Symposium. Role-based versus task-based business processes can play a major role in driving operational performance of any department or organization. Regardless of how the query is communicated, it needs to meet all of the following criteria: Although verbal queries may be prevalent in the physician practice setting due to the close working relationship and quick turnaround of patient visits, it is important to follow guidance requiring their recording. Assists in educating physicians regarding documentation to the highest level of specificity for all conditions and complications being addressed and treated. Outpatient CDI Programs: Are They Poised for Effectiveness and Success? Depending on the type of practice, such as specialty versus general medicine, E/M level distributions should be compared to national trends. Many larger facilities encourage providers to code their levels of service and procedures performed. 2019. http://bok.ahima.org/PdfView?oid=302735. 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. www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf. 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. 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. 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. Number of diagnoses or management options, Amount and/or complexity of data required for review, Risk of complications and/or morbidity or mortality. 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. 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. 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. patient health information. 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. Improvement in diagnosis capture does not equate to clinical documentation excellence, which can be interpreted as the physician’s ability to become a high-performing communicator of patient care. November 21, 2019. ACDIS members save $150 off the registration fee. 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. These conventions are incorporated within the Alphabetic Index and Tabular List of the ICD-10-CM as instructional notes. 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, … There are numerous opportunities now to extract data out of the EHR. 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. They ensure accuracy and quality among medical coders, doctors, … CMS measures the Medicare Fee-for-Service (FFS) improper payment rate through the Comprehensive Error Rate Testing (CERT) program. By focusing too closely on reimbursement, we are overlooking the vitally important component of true documentation improvement. May 4th, 2020 / By Julie Salomon, BSN, RN. 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. Follows up on open queries to ensure physician response. Clinical Documentation Improvement for Outpatient Care: Design and Implementation. 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. Apply to Document Specialist, Specialist, Clinical Director and more! This provision was finalized in response to provider burnout due to the administrative burden related to documentation requirements. The concern over this type of reimbursement was that quality of care was being sacrificed. 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. 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. A CDI professional can also be a valuable part of an analytics team. 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 … JOURNAL of AHIMA—the official Integrity requires, as a whole, redefining the current mission of CDI. … CDI and coding professionals can focus on areas related to coding and reporting as well as other documentation that supports quality initiatives to improve patient outcomes. For example: Section I.C: Chapter-Specific Coding Guidelines, This section addresses guidelines related to chapter-specific diagnoses and/or conditions. Specifically, documentation should describe each condition as acute, chronic, exacerbated, or resolved to clearly convey its current status and relationship to the current episode of care. CMS. Provides detailed project design documentation, project plans and process flows to present to leadership. In the outpatient setting, providers are reimbursed for their professional services based on E/M codes. Risk adjustment methodologies assign families of diseases to a cost based on severity and projected use of resources. These documented conditions are then translated into reportable codes and this reported data is then used to predict costs for the following year for Medicare Advantage and/or commercial enrollees. To think that present-day CDI efforts are benefiting the patient, the physician, all healthcare stakeholders, and the achievement of a high-performing revenue cycle is a fallacy. We must respect the medical record with the patient in mind; our overall operating principle must consider the notion of the patient. Patient presents with a symptom and no definitive diagnosis is made. 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. AHIMA. 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. 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. To produce a medical record that is the most efficacious communication tool for all healthcare providers rendering care, in each case; To provide accurate, specific, detailed medical documentation to effect enhanced patient safety, as well as effectiveness of care efforts; To provide information for external reviewers of all types, free of ambiguity, inconsistency, or clinical incompleteness; To provide a medical record that is defensible relative to external audits; and. 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. 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. 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. 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. keeps readers current on emerging Providers can use either 1995 or 1997 documentation guidelines when selecting the appropriate level for the patient 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. CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes. 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. Glenn is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays. As already mentioned, accurate and precise provider documentation is more important than ever in the changing landscape of provider reimbursement and quality initiatives. 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. Perform concurrent reviews and offer providers feedback to improve completeness and specificity in documentation to support ICD-10-CM/PCS, CPT, and HCC coding, Conduct chart reviews and any necessary provider education for compliance with quality reporting initiatives, Perform retrospective chart reviews for coding compliance and quality measures, Collaborate with team members to aggregate findings from clinical documentation reviews (both retrospective and concurrent) and design educational content and remediation strategies for both individual providers and provider groups, Coach the provider on opportunities for improving clinical documentation based on annual compliance review findings, Collaborate with team members on ways to improve EHR functionality in support of clinical documentation coding trends and requirements, Translate feedback from providers, CDI professionals, coding professionals, and compliance into content enhancements in the EHR, Design, test, and implement revised drop-down menus and other enhancements to assist providers in improved documentation and coding completeness, Collaborate with providers to improve existing standard note and template functionality, Collaborate with the EHR vendor to validate the embedded clinical terminology system within the EHR is appropriately mapping to the correct ICD-10-CM and/or SNOMED CT codes, Prepare physicians for the documentation changes effective in 2021, Review times documented for telehealth services, Schedule, prepare, and lead meetings with practices focused on documentation, coding, and quality performance gap closure, and develop and implement follow-up activity, Lead or provide education/training to clinical care (providers, nurses, etc.)

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