CDI seen as a key solution to meeting regulatory policy changes.
One thing is inevitable this time of year for all of us in healthcare: change is in the air. You either thrive amid it or hide, but even those best at hiding ultimately cannot escape. The question I often ponder is this: why hide at all?
Each year we are hit with myriad changes in areas such as coding, quality measurements, and payment polices, just to name a few. And in the wake of these changes, we are left to struggle on how to adapt. Only the strong survive.
And let’s face it, we are up to our necks in administrative burdens. This year is no different. There is one major way we can make effective changes in our practices that will enable us to succeed once and for all, and the solution is clinical documentation integrity (CDI).
CDI is the key to all improvements, and it helps make us ready for the next big issue. While we wait for the final rule on fee schedules, or how the changes may be applied, or what’s next for quality, there is so much we can do to be ready in our practices and our facilities. Here’s some tips on helping you be prepared for any changes that may come your way:
Once you do this, tie all these elements together. If you work on your top 10 conditions, revise your templates for evidence-based medicine, and work to clean up your intake forms, you will hit not only coding guidelines, but also quality measures (no matter what they end up being).
You will experience fewer rejections, have stand-up documentation for easier appeals, and produce some amazing documentation that goes a long way in truly describing each patient’s clinical condition, which now becomes a win-win.
If we work on strategy to take the administrative role out of healthcare and instead focus on documenting for the actual clinical conditions, we can easily get to the point where the amount of changes that hit our practices each year will just be a small blip on our radar. This is where we need to head for the future advanced payment models and initiatives coming our way. The implementation of CDI will help carry you forward.
Program Note: For more information on this subject listen to Rhonda Buckholtz today on Talk Ten Tuesdays at 10 a.m. ET. Register to listen.
Having worked in clinical documentation integrity (CDI) in a variety of roles, I have heard a lot of advice when it comes to the timing
Let’s talk about the term “attending physician.” The simplest definition is the physician primarily responsible for a hospitalized patient’s care. While there may be many
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