AI-powered solutions must align with applicable coding guidelines.
Electronic health records (EHRs), clinical documentation software, and enabling technologies are working together in new and exciting ways to create accurate, robust, and concurrent patient documentation that improves quality of care while protecting healthcare organizations’ financial integrity.
But as I wrote last Tuesday in Part I of this series, compliance remains at the top of everyone’s list, and for good reason.
Because they’re bolstered by machine learning, deep domain knowledge, and vast amounts of health data, technologies powered by artificial intelligence (AI) can and do make physicians and clinical documentation improvement (CDI) professionals more accurate and efficient.
To support organizations in their compliance efforts, however, these same technologies must be evidence-based and work in accordance with applicable laws and coding guidelines – all under the umbrella of an advanced practice CDI program.
Advanced-practice CDI programs enable collaboration between the CDI team, physicians, and professional coders to create the most precise and accurate final coding. At the heart of these programs are the CDI professionals who combine extensive clinical expertise, patient care experience, and astute regulatory knowledge with the applicable organizational policies and procedures to improve coding compliance while also preventing costly denials.
Advanced-practice CDI professionals safeguard the compliance of CDI processes through a range of accepted best practices that include oversight and monitoring. For example, relative to computer-assisted physician documentation (CAPD) clarifications, CDI professionals provide complete transparency and audit reports that include not just the physician responses, but also the sources of clinical evidence that support final diagnosis and coding.
Throughout the entire CDI workflow, avoiding “leading” queries is essential. That is, advanced-practice CDI professionals will only offer recommendations that are highly consistent with available, documented evidence; otherwise, these queries may “lead” a physician to a particular potentially problematic conclusion.
CDI compliance oversight will also include quality reviews of clarifications to assure clinical evidence and validity, training for leadership and CDI staff on evidence-based documentation strategies, and the establishment of a multidisciplinary steering group.
At the end of the day, advanced-practice CDI programs that rely on compliant, best-practice driven queries create a great deal of value for the entire health system, from the patient to the provider and the hospital.
CDI professionals at the center of these programs combine their expertise and experience with AI-driven solutions that support clinical decision-making, streamline access to evidence-based content, and create a collaborative, closed-loop, compliant program.
The Centers for Medicare & Medicaid Services (CMS) released in its 2025 Outpatient Prospective Payment System (OPPS) Final Rule a new Conditions of Participation (CoPs)
A recent report from US News was published regarding an October article in the Journal of the American Medical Association (JAMA) about the increase in
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 ICD10monitor. Powered by MedLearn Media.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
