EDITOR’S NOTE: Colleen Deighan will be conducting a Talk Ten Tuesdays Listener Survey on CDI today.
When you read these words, “outpatient CDI,” what comes to mind for you? Risk adjustment, documentation integrity for emergency department and observation services, medical necessity to support the next level of care, authorization, evaluation and management (E&M) services, or some other area of equal importance?
The American Health Information Association (AHIMA) CDI toolkit defines outpatient CDI as “a very broad concept and can describe any CDI effort not associated with an inpatient claim”. Yes, I’d say that’s broad!
Hospital and healthcare systems have experienced the shift of care from inpatient to outpatient and from fee-for-service (FFS) to value-based payment models for the past 15 or so years. All Medicare value-based programs are designed to change how healthcare is delivered and paid for.
The goals of The Center for Medicare and Medicaid Services (CMS) value-based programs are to improve patient care, reduce healthcare costs and improve population health—sometimes referred to as the triple aim. This shift is one of the key reasons outpatient CDI programs and clinical documentation integrity specialists (CDISs) have become an important and valuable resources for hospital outpatient departments and physician practices across the continuum of care.
Implementation of an outpatient CDI program should be well planned out, involve key stakeholders, and align with overall organizational goals. To ensure the biggest impact and return on investment (ROI), a key, first step is to start with a full assessment to determine which opportunities and gaps exist within your organization.
An assessment begins with data including analysis of the data and validation of the data with chart reviews to identify gaps in documentation along with coding accuracy. Once you have validated the data then you can begin to prioritize where to begin your organizations efforts and plan a timeline for implementation that includes a skills assessment, education and training of CDI staff, coding staff and providers.
Just a few weeks ago the Association of Clinical Documentation Specialists (ACDIS) recognized the profession with their annual CDI week celebration. As part of CDI week, a “state of the industry” survey was completed and included several questions about outpatient CDI.
Over the coming weeks we’ll explore the diverse areas of outpatient CDI with the hopes of expanding awareness and need for documentation integrity within outpatient services. The patient is at the center of everything we do. The accuracy of the documentation and the accuracy of coded data impacts healthcare organizations and patient care.
The time is now for outpatient CDI.
Programming Note: Listen to Colleen Deighan report this story live today on Talk Ten Tuesdays, 10 Eastern.
All hospitals are struggling to some degree, with increasing payer denials and ongoing post-payment chart reviews resulting in a time-consuming process. According to a recent
Clinical validation (CV) denials are plaguing us lately. When I work on projects entailing medical record review, I must admit that it is not unusual
Please log in to your account to comment on this article.
ICD10monitor has teamed up with renowned CDI expert Dr. Erica Remer to bring you an exclusive webcast on how to recognize sepsis, how to get providers to give documentation that will support sepsis, and how to educate to avert sepsis denials. Register now and become a crucial piece of the solution to standardizing sepsis clinical practice, documentation, and coding at your facility.
Optimize your inpatient 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 CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. Participants will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P., as she helps you navigate advanced inpatient CDI technologies, regulatory changes, and system interoperability. Angela will provide actionable strategies for integrating AI and predictive analytics into CDI practices, ensuring seamless system interoperability, and maintaining compliance with evolving regulations. Attendees will learn to select and implement advanced EHR systems and CDI software, leverage data analytics to enhance documentation accuracy, and stay audit-ready with the latest compliance updates. Real-world case studies and practical tools will empower you to drive continuous improvement in CDI, improve patient outcomes, and enhance organizational efficiency. Don’t miss this opportunity to advance your CDI practices and stay ahead in this dynamic field.
Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P, for an insightful webcast on improving inpatient clinical documentation integrity (CDI). Inaccurate documentation can lead to misdiagnosis, improper treatment, and compromised patient safety. High workloads, lack of standardized practices, and outdated EHR systems contribute to these issues, affecting care quality and financial outcomes. Angela will offer practical strategies and tools to enhance accuracy, consistency, and timeliness in documentation. Attendees will learn to use standardized templates, checklists, and advanced EHR systems, while staying compliant with regulations. Improve patient care, ensure accurate billing, and reduce audit risks with actionable insights from this essential webcast.
This webcast, presented by Tiffany Ferguson, LMSW, CMAC, ACM, addresses the critical gap in Social Determinants of Health (SDoH) reporting for pediatric populations. While SDoH efforts often focus on adults, this session emphasizes the unique needs of children. Attendees will gain insights into the current state of SDoH, new pediatric Z-codes, and the importance of interdisciplinary collaboration. By understanding and applying pediatric-specific SDoH factors, healthcare professionals can improve data capture, compliance, and care outcomes. This webcast is essential for those looking to enhance their approach to pediatric SDoH reporting and coding.
Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, VP of CDM, for a webcast addressing oncology service coding challenges. Learn to navigate coding for infusions and injections alongside Evaluation and Management (E/M) services, ensuring compliance and accurate reimbursement. Gain insights into documenting E/M services for oncology patients and determining medical necessity. This webcast is essential to optimize coding practices, maintain compliance, and maximize revenue in oncology care.
During this webcast Dr. Ronald Hirsch delves into the inpatient admission order process including when to get it, when it becomes effective, its impact on billing and payment, who can write it, how to cancel it, the effects on the beneficiary, and more. You’ll leave with a clear understanding of inpatient orders and guidelines for handling improper orders that you can implement immediately.
Michelle Wieczorek explores challenges, strategies, and best practices to AI implementation and ongoing monitoring in the middle revenue cycle through real-world use cases. She addresses critical issues such as the validation of AI algorithms, the importance of human validation in machine learning, and the delineation of responsibilities between buyers and vendors.
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!
