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One of the biggest lingering questions facing the healthcare industry today is this: how do we keep physicians from becoming administrators rather than clinicians?

Having a quality clinical documentation improvement (CDI) program in place can grant physicians the necessary flexibility and time to dedicate to their patients while still providing an avenue for them to ensure complete and accurate documentation in their patient’s medical record.

CDI specialists should be the conduit between physicians and downstream revenue cycle professionals, having in-depth clinical knowledge and a strong working knowledge of documentation requirements for coding and reimbursement. The CDI specialist should work on the floor or in the unit while the patient is in the bed, reviewing documentation captured at the point of service.

Too many disruptions during the physician workflow, such as retrospective queries post-discharge, can detract from the quality of care provided to the patient.

Tools such as templates in an electronic health record (EHR) are invaluable when used appropriately. For example, tailoring the documentation templates toward the physician’s specific patient type can minimize unnecessary steps in the workflow, but too many templates can bog down the physician and at times force the physician to use generic language or documentation in order to move on to the next patient. 

By incorporating the use of specified tools that work into the physician’s workflow and implementing a quality CDI program with real-time review and interaction, the burden of administrative work can be shifted away from the physicians, allowing them to dedicate their time and attention to the care and well-being of their patients. ICD-10 has increased the documentation specificity requirements, and in many cases it changed how we document and receive reimbursement for care provided. For example, acute myocardial infarction (AMI) is now considered “acute” for four weeks from the time of the incident, instead of the eight weeks previously recognized in ICD-9.

Another example includes the inability to assume some of the causal relationships in ICD-10 that we previously could see in ICD-9. In ICD-10, we have more stringent rules to which to adhere. Your CDI specialists should be well-versed in the ever-changing documentation requirements in order to minimize the burden placed on physicians.

Because we are in the early phases of ICD-10, we have yet to experience the full impact and level of detail that’s being captured during the coding process.

Your CDI specialists, working in tandem with your physicians, will ensure that ongoing detail and specificity will be available for coders in order to allow them to minimize denials and lost revenue for your organization.

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