Hayes' Healthcare Blog

How to Fast Track Your Outpatient Clinical Documentation Program

Posted by Corliss Collins on December 17, 2014 at 9:00 AM

Implementing a clinical documentation improvement (CDI) initiative for outpatie121714nt settings is a crucial element of ensuring your coding is accurate and your claims are billable. CDI drives what can be coded and billed; it ensures descriptions of patient encounters, assessments, treatment planning and dates of service in the clinical note are correct.

Traditionally, when we discuss clinical documentation improvement efforts and resources; the focus has been primarily allocated for inpatient services. However, the Accountable Care Act (ACA) and the Institute for Healthcare Improvement (IHI) are encouraging medical communities to broaden the scope of reach to include outpatient settings. The quality of patient care and value of services rendered is determined by the comprehensiveness of the clinical encounter note and treatment outcomes.

In a recent survey, more than 270 hospitals were asked if they had an active clinical documentation improvement (CDI) program; 66% said yes, while 34% were in the discussion and assessment phase of determining where to begin, cost and value of establishing a formal CDI program. Statistics indicate that significant increases in reimbursements and revenue gains as a direct result of implementing a CDI platform.

So how do you fast track your organization to CDI excellence?

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Topics: CDI, clinical documentation, ICD-10, documentation

ICD-10 Dual Coding: 5 Key Reasons to Keep on Schedule

Posted by Edwin Hartai on July 16, 2014 at 3:07 PM

The delay of ICD-10 has caused healthcare providers to re-evaluate the time and costs associated with planning and implementation efforts, including those devoted to dual-coding. President Obama signed the SGR bill (H.R. 4302) on April 1, 2014, effectively delaying ICD-10 until October 1, 2015 at the earliest. Many organizations were just getting their dual coding efforts underway and others were trying to give their coders at least six months of practice to minimize the impacts on productivity following the implementation of ICD-10.

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Topics: CDI, clinical documentation, ICD-10, clinical documentation improvement, coding, delay, coder, budget, documentation

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