Clinical Documentation Improvement for Outpatient Care: Design and Implementation. Role-based versus task-based business processes can play a major role in driving operational performance of any department or organization. Professionals issuing queries must adhere to the following guidelines: Please refer to AHIMA/ACDISâs âGuidelines for Achieving a Compliant Query Practice (2019 Update),â available online in AHIMAâs HIM Body of Knowledge at bok.ahima.org, for additional details on writing compliant queries, including query examples. Association of Clinical Documentation Integrity Specialists (ACDIS) This membership association was created especially for CDI professionals that brings together people of â¦ In capturing the essence of the verbal discussion, timely notation of the reason for the query (exact date/time and signature), clinical indicators, and options provided should be recorded and tracked in the same manner as written queries and be discoverable to other departments and external agencies.â Provider response to the query must be documented in the permanent health record in order to be coded. The ACA introduced a permanent risk-adjustment program (Section 1343). Documenting in the health record, especially in electronic health records (EHRs), is becoming an increasingly challenging task for many providers across the continuum of care. CMS Evaluation and Management Services. Enhanced reimbursement should be thought of and treated as a byproduct of solid documentation reflective of medical necessity for inpatient care, continued hospitalization stay, discharge stability, appropriate resource consumption, and utilization review/management processes under the Conditions of Participation, as well as the quality of care delivery, achieved outcomes, and accurate clinical validation of all assigned ICD-10 codes and DRG assignment. 5 (May 2016): 22-25. http://bok.ahima.org/doc?oid=301436. According to the AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice (2019 Update), all queries, including verbal queries, should be documented in writing to demonstrate compliance with all query requirements to validate the essence of the query. Well-established program: Brought to you by the Association of Clinical Documentation Integrity Specialists (ACDIS), this Boot Camp from the industryâs only dedicated CDI association provides the best-in-class education you expect. Recently, two associations representing the CDI profession moved to change from clinical documentation improvement to clinical documentation integrity, to reflect a renewed focus upon integrity of the record. In the outpatient setting, providers are reimbursed for their professional services based on E/M codes. In an article published by the American Medical Association (AMA), the key elements of the E/M office visit overhaul include: An opportunity now exists for clinical documentation integrity (CDI) and coding professionals to incorporate this upcoming change into their provider education. The scope of work in the profession remains fundamentally the same: review of records for the purposes of increasing reimbursement, without associated improvement in the integrity of the record. This section provides general rules for reporting additional diagnoses. November 21, 2019. Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.1. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Most medical necessity denials are attributable to insufficient and/or poor physician documentation, something CDI is not currently addressing through the query process. These conventions are incorporated within the Alphabetic Index and Tabular List of the ICD-10-CM as instructional notes. Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. The traditional fee-for-service model has been declining in popularity by health insurers who have implemented varying types of managed healthcare plans over the years to decrease costs and encourage more efficient delivery of healthcare through risk sharing. Modifying MDM criteria toâ¯move away from simply adding up tasks to focus on tasks that affect the management of a patientâs condition. ACDIS provides the resources you need to become a Certified Clinical Documentation Specialist (CCDS) for a variety of specialized disciplines including education in anatomy and physiology, pathophysiology, pharmacology, medical coding guidelines, and more. For example, if a patient came in for an office visit for a cough and during the examination the provider documented that the patient is also treated with medication for diabetes and hypertension and has a history of right leg amputation status following a motor vehicle accident. November 1, 2019. https://www.ama-assn.org/practice-management/cpt/em-overhaul-aims-reduce-physicians-documentation-burdens. See Table 1 for a quick overview of the ICD-10-CM Official Guidelines for Coding and Reporting. The Clinical Documentation Integrity (CDI) Manager reports to a Director within a specific division of the organizationâ¦The manager has overall responsibility for the daily planning, work scheduling and coordination, and operational performance of the defined Clinical Documentation Improvement programâ¦ A payment transfer formula is then utilized to identify risk adjustment payments between the plans. 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