Clinical Documentation Improvement (CDI)
successful clinical documentation practices ensure best quality patient care and timely reimbursement.
Today's healthcare organizations recognize that proper clinical documentation is critical to their operations. Successful organizations accurately reflect the care that was provided and the status of each patient, which in turn streamlines and maximizes reimbursement. A great Clinical Documentation Improvement (CDI) Consultant can help you navigate and elevate your documentation practices to the next level. STAR offers two levels of CDI services:
FULL-SERVICE CDI:
STAR's CDI Experts are fully credentialed with RN and CCDS credentials. They guide and educate providers to improve their documentation efforts, and act as a liaison between the providers and the coding team. They understand the intricate balance between clear and concise documentation and clinical evidence, creating compliant queries when further clarification is needed. Furthermore, they have deep knowledge of ICD-10-CM and PCS code assignments that not only meet medical necessity, but also are the highest specificity and correct sequence, validating the MS-DRGs as well as the CC/MCC codes to determine if they are supported by the documentation.
CDI AUDITS:
Does your organization have an internal CDI Team? Then you should be planning your CDI Audit schedule as part of your CDI Program. STAR’s RN/CCDS-credentialed CDI Experts can work concurrently or retrospectively on the accounts reviewed by your internal CDI Staff, make recommendations on potential and missed query opportunities, and reconcile the accounts by following them through to final coding. The monthly report will provide the CDI Staff accuracy scorecards, and give a dashboard comparison of their improvement over time. Additionally, it will give your leadership recommendations for the overall effectiveness of your internal CDI Program.
Both levels of CDI activities measure the impact on SOI/ROM, changes in financial impact, and the impact on quality metrics. Both levels include a Tracking Tool with query evaluation for labs, radiology, vitals, orders, wound care and more. The Tracker includes DRG validation (for IP), E&M level validation (for ProFee) and gives a breakdown of the overall total financial impact for each month (stats so important to your Revenue Cycle Team, CFO, Board of Directors and other Sr. Leaders!). Our summary reports show the scorecards and financial stats over time, along with our recommendations, allowing for customized provider education, complete with redacted screen shots of their actual accounts to really engage your providers.
Star's 5-step to clinical documentation success
1. Assess documentation for coding readiness. Focused documentation audits by specialty are critical to determining patterns of missing information that may impact coding and reimbursement under ICD-10 and CPT. By understanding the clinical areas impacted most by vague or unclear documentation, your organization can tailor clinician education and improve documentation processes where needed.
2. Analyze the impact on claims. Do you know how missed coding opportunities in ICD-10 and CPT will impact reimbursement? If clinical documentation is incomplete, coding will be inaccurate and claims will be impacted. Concentrate initial improvement efforts on those providers and/or service lines that offer the greatest opportunity or risk in terms of revenue impact.
3. Implement progressive clinician education. There has always been a disconnect between the language clinicians use to document care and the language coders need in order to code from the documentation. Recent CMS guidelines prevent coders from questioning diagnoses or suggesting intended diagnoses to providers. If it isn’t documented, it can’t be coded. Progressive education allows medical staff to adjust documentation practices which in turn allows the coders to accurately report the diagnoses and procedures performed.
4. Establish a concurrent documentation review program. When a CDI Expert can review documentation and query clinicians about inconsistencies before the patient is discharged, the complete clinical status, including secondary diagnoses and complications, can be captured. Many organizations are finding it essential to implement concurrent review programs.
5. Streamline clinical documentation workflow. By having a monthly random sampling of accounts selected for CDI audit that focuses on integration of documentation within clinical workflow, STAR CDI Experts can uncover trends in missing or vague documentation which leads to inaccurate coding. These CDI audits provide clinically driven concepts and alert the STAR CDI Experts to query clinicians for additional information, saving time and improving efficiency when the accounts are received by the coders.
Available for Inpatient, ProFee & Outpatient, Long Term Care and HCC chart reviews.
Call STAR today to schedule your CDI Services!