Clinical Documentation Improvement

Why Should You Attend:

The upcoming ICD-10 code set will require explicit documentation of conditions and treatments in order to support the severity of patients under treatment as well as allow for the significant specificity required by this new code set. Ambiguous documentation and generic coding will no longer guarantee reimbursement, but will possibly generate a claims denial for lack of medical necessity.

This session will review the theory of high-quality clinical documentation which has the support of healthcare regulatory guidelines and peer-review research. Additional consideration involves medical outcomes that may result in legal actions. When clinical documentation is vague, missing key elements and conflicting statements, the provider may find that he/she is handicapped in supporting medical decisions and patient results, particularly when the result is a negative outcome for the patient.

In today’s healthcare environment, many patients have become educated consumers of medical services. They are more inclined to request their own medical record, carefully review explanation of benefits from payers, and request a review of any information they deem to be incomplete or questionable.

This webinar will review examples of documentation that does not meet the standard of high quality clinical documentation, including:

• Review of 7 criteria that all entries in the medical record should include
• Impact of documentation on coding and claims
• Establishing a CDI team
• CAMP methodology of documentation improvement

Areas Covered in the Webinar:

• Significance of abnormal lab results. How to query provider.
• Measurement of lesions, when taken and inclusion of margins. Why it matters and how reimbursement may be affected.
• Start and stop times and methodology for infusions and discrepancies in billing. Complete reporting for administration and substance.
• Diagnostic testing and medications should be supported in a diagnosis. Unsupported documentation may cost you money.
• Depth of wounds and cause should be clear. Clarity needed for both depth and origin of wound.
• Severity of illness. Hospitals and payers are increasingly scrutinizing patient severity. Lack of detail costs money.
• Diagnosis present on admission? Certain conditions do not generate additional revenue if occurrence after admission.

Who Will Benefit:

• Coding
• Billing
• Revenue Cycle
• Physicians
• Mid-Level Providers
• Nurses
• Claims Follow-Up
• Managers

Instructor Profile:

Dorothy D. Steed (CCS, CDIP, COC, CPCO, CPUM, CPUR, CPHM, CPMA, ACS-OP, CCS-P, RCC, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR) is an independent healthcare consultant and educator in Atlanta. She was a Medicare specialist for a large hospital system and a physician coding audit supervisor for another hospital system, with 39 years of experience in healthcare. Additionally, she is an instructor at a state technical college in Atlanta, provides auditing and training in both facility and physician services, and has been a speaker at several healthcare conferences.

Ms. Steed has written articles for several medical publishers and served as a contributing author for medical billing and coding training material. She writes online courses, and is an AHIMA certified ICD-10 trainer, both CM and PCS. Ms. Steed is credentialed in medical coding, clinical documentation improvement, medical billing, medical auditing, utilization management, healthcare management, healthcare compliance and patient accounts. She holds a Bachelor’s degree with a major in business and minors in both criminal justice and sociology.

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