Nora Blankenbecler is the Director of the Health Information Management program at Mountain Empire Community College, and one of our featured speakers at this year’s Head for the Hills Conference. Her session on Clinical Documentation Improvement programs is sure to be packed with all kinds of information on medical documentation and is definitely a talk you won’t want to miss!
“The purpose of a CDI (Clinical Documentation Improvement) program is to initiate concurrent and, as appropriate, retrospective reviews of inpatient and outpatient health records for conflicting, incomplete, or nonspecific provider documentation. These reviews usually occur on the patient care units or can be conducted remotely (via the electronic health record). The goal of these reviews is to identify clinical indicators to ensure that the diagnoses and procedures are supported by ICD-10-CM codes. The method of clarification used by the CDI communications are also methods used to make contact with physicians and other providers. These efforts result in improvement in documentation, coding, reimbursement, and severity of illness (SOI) and risk of mortality (ROM) classifications.”
The need for complete and accurate documentation has taken a more important role with recent changes, beginning with the adoption of Medicare Severity Diagnosis Related Groups (MS-DRGs) in 2007 for hospital inpatient prospective payment in order to better reflect the patient’s severity of illness (SOI) and expected risk of mortality (ROM). The patient’s principal diagnosis and co-morbid conditions determine these two assessments. In October 2008, CMS began to require a Present on Admission (POA) indicator for all coded diagnoses to identify conditions that are present when a patient is admitted from those that are acquired once in the hospital. In addition, drivers in the Medicare Advantage or Part C payment structure rely heavily on clinical documentation and coding for capturing of clinical diagnoses. This coded data drives reimbursement structure and captures resource intensity care. Coupled with these developments, healthcare continues to experience the scrutiny of compliance and regulatory bodies that require more accurate and specific data. Improved clinical documentation plays a part in compliance with national core measures.
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Southwest Virginia Graduate Medical Education Consortium 
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