We meet you wherever you are in your CDI journey with solutions that include encounter prioritization, workflow, analytics, and services that can be packaged to take your program further. 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… Often, name changes reflect little substance, and this is no exception. Providers also need to be aware that their documentation is captured through many types of coded data including, but not limited to, ICD-10-CM/PCS, CPT, RxNORM, SNOMED CT, and Logical Observation Identifiers Names and Codes (LOINC). Key performance indicators (KPI)/dashboard (for exam ples, see the online appendix for this Practice Brief). This section also addresses format and structure of the classification. 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. A payment transfer formula is then utilized to identify risk adjustment payments between the plans. These conventions are incorporated within the Alphabetic Index and Tabular List of the ICD-10-CM as instructional notes. Clinical documentation specialists manage clinical trial and service documents. This provision includes revisions to the E/M office visit CPT codes (99201-99215) code descriptors and documentation standards effective January 1, 2021. Clinical Documentation Improvement for Outpatient Care: Design and Implementation. Patient presents at the hospital clinic for examination or testing without a referring diagnosis, symptom, or complaint. Bullet points are the key component used to determine the type of examination. Clinical documentation integrity (CDI) programs are highly ingrained in most hospital and healthcare facilities. 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. As already mentioned, accurate and precise provider documentation is more important than ever in the changing landscape of provider reimbursement and quality initiatives. Modifying MDM criteria to move away from simply adding up tasks to focus on tasks that affect the management of a patient’s condition. 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. 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. Designed for the experienced coders or audtiors, AAPC's CDEO online training course covers the benefits of clinical documentation improvement (CDI) programs, documentation requirements, quality measures, payment methodologies, and clinical conditions including common signs and symptoms, typical treatment, documentation tips and coding concepts. 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. The adage of “tell me how I am measured, and I will perform accordingly” applies in this instance. So why is it important for the providers to report additional diagnoses even though they are not going to link to a service (CPT code) line? Barnette, Erin et al. However, they cannot use both guidelines. Prior encounter information may be referenced in queries for clinical clarification or validation if it is clinically pertinent to the present encounter. CDI supports positive outcomes in patient care, quality, cost, resource consumption, reimbursement, and revenue cycle processes. It will be helpful to educate providers on hierarchical condition categories (HCCs). Risk adjustment methodologies assign families of diseases to a cost based on severity and projected use of resources. Key highlights include: Outpatient (provider office, clinics, etc.). Are you going to get vaccinated against COVID-19 when the vaccine becomes available for you? These guidelines assist providers in determining the most appropriate level of service to bill for their E/M services by providing guidance on what elements need to be included in their documentation. Enter alternative healthcare reimbursement models: The Affordable Care Act (ACA) ushered in a new era of healthcare that applies risk adjustment to patient populations and introduced value-based 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. Director, Clinical Documentation Integrity at Revenue Cycle Business Services . Theoretically, if a patient’s/enrollee’s chronic condition becomes severe, the patient will then require extra healthcare services. 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