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CLINICAL DOCUMENTATION IMPROVEMENT

As patient care continues to move from inpatient to outpatient, the HIM field continues to expand in leaps and bounds opening up more opportunities. Recent initiatives such as the ICD 10 CM and ICD 10 PCS have brought in Clinical documentation improvement programs to the forefront.


Clinical documentation is the foundation of every health record. The documentation of the patient's condition and the coding drives the severity and the reimbursement.


High Quality documentation enhances the outcomes and also serves as a beacon light for the organization to prepare for a variety of future payment methodologies and new reforms.


Medicare Guidelines insist on SPECIFICITY OF THE CONDITION that must be present in order to choose and apply a code for reimbursement. Clinical documentation that is accurate, precise and complete can strengthen an organization to handle the regulatory compliance reviews including the RACS, ZPICs and MIC programs.

OUR CDI OBJECTIVE:

The purpose of our CDI program is to enable the concurrent and retrospective reviews of inpatient health records for inadequate and incomplete or non-specific provider documentation. The documentation review can be performed in person or remotely via the EHR complying with HIPAA requirements.


Our CDI specialists works to ensure the documentation in the medical record captures the true acuity of our patients. Accurate documentation will reflect appropriate severity of illness and risk of mortality to support resource intensity and length of stay for our patients.


Our documentation specialist support to educate the physicians on the importance of coding and the documentation impact on coding. Our objective of this program is not to establish a method of "gaining reimbursement" or increasing the hospital case mix index. We aim ensuring the correct severity of the patient's illness is captured in the hospital databases in order to provide proof of severity for regulatory compliance.


Our CDI Program:

Our CDI program is designed to suit the requirements for outpatient and also acute care hospital. Recent initiatives such as the MIPS and MACRA have created the increasing focus on the outpatient clinical documentation program. The only way the practitioners can achieve quality care and manage costs simultaneously is through accurate, precise and complete documentation.


Rely On Us - Outpatient CDI initiatives

We first attempt to understand your organization data and how it affects the reimbursement and documentation is key to success of our Outpatient CDI program.

The Outpatient CDI initiatives are a four step process which strategically improves the outcomes:

Rely On Us - Inpatient CDI initiatives:

The inpatient CDI program is a very successful initiative to enhance and improve the clinical documentation. Although, CDI programs have traditionally lead to immediate financial success by shifts in DRG and Case Mix index, the CDI program impacts far beyond the revenue enhancement tied to the claims today.


The work of a hospital based physician who provides the best possible care to patients is accurately reflected in the documentation. The documentation of a medical record is like a mirror which reflects the true severity of illness and the quality of care delivered. These mirror images are linked to a variety of value based model initiatives like accurately capturing the Hospital acquired conditions and patient safety indicators (PSI) and the prompt reimbursement of the claims.


We believe that our CDI program's success is based on the future implications pertaining to improving the quality of care and effectiveness of patient care. CDI program at Rely On Us make the healthcare providers to initiate their journey towards quality care. We think proactively for the documentation impact on reimbursement and do not just focus on the revenue of present claims which in turn contributes to the growth and longevity of our customers.


Our Inpatient CDI focuses on a four step process:

We analyse the data for any documentation gaps with our unique methods and record review.

  • Educate the HIM Staff.
  • We engage the providers identifying the need for clinical documentation improvement by our certified group of CDI Specialists.
  • We also stay ahead of quality indicators measures such as readmissions, value based payment indicators, risk adjustment etc.
  • We work on the following aspects as part of our Inpatient CDI program.