Improving CDI Programs and Alternative Methods and Solutions for Documenting a Clinical Encounter

Learn best practices for Clinical Documentation Integrity, identify documentation gaps, and enhance physician communication skills.

Clinical Documentation Integrity programs, formally known as Clinical Documentation Improvement programs have existed since 2008 with the advent of the MS-DRG coding and billing system. The need for complete and accurate documentation has evolved to today where payers are expecting to see an accurate and complete account of patient care, incorporating the telling and describing of the patient story and the establishment of medical necessity. CDI processes have not evolved to meet the changing needs and requirements of physician documentation. By attending this course, attendees will learn how to define best practice standards and principles of documentation, be able to identify true insufficiencies in documentation and even more importantly how to address with the physician. Attendees will become familiar with the critical nature of the physician’s clinical reasoning and clinical judgement, be able to incorporate these elements into the chart review process, recognize documentation insufficiencies that detract from a complete assessment and plan, and converse with physicians to address and prevent clinical validation denials. Attendees will be able to review a record efficiently in 5 minutes and hone in areas of documentation to address, helping physicians achieve true physician documentation excellence with proactive preemptive denial avoidance documentation.

Learning Objectives

• You will be able to define standards and best practices of physician documentation.
• You will be able to describe common documentation insufficiencies that contribute to medical necessity and clinical validation denials as well as level of care and DRG downgrades.
• You will be able to discuss with the physician how to strengthen the documentation and meet the best practice standards of documentation efficiently and effectively.
• You will be able to identify documentation insufficiencies contributing to denials using real case studies and learn how to address and communicate with physicians.