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

Agenda

The Role of the Medical Record- Going Beyond Reimbursement

• The Medical Record Serves a Myriad of Purposes Beyond a Repository for Physician Documentation That Supports Coding, Billing and Reimbursement. Learn How the Record Represents a Wide Array of Purposes Supporting and Facilitating Quality Focused Patient Centered Patient Care, All Fundamentally Dependent Upon Complete and Accurate Clinical Documentation That Best Describes, Shows and Tells the Patient Story
• Understand How the Electronic Health Record Has Degraded the Quality and Value of the Medical Record and What Steps Can Be Taken to Drive Clinical Documentation Excellence Through Deployment of Strategies That Engage Physicians
• Plan, Develop and Organize and Implement an Effective Strategy to Enhance the Quality and Completeness of the Medical Record, Utilizing a Team-Based Approach Incorporating All Stakeholders in a Multidisciplinary Approach on Behalf of the Patient and Quality Achieved Cost Effective Patient Outcomes

Addressing Insufficiencies in Physician Documentation- Expanding Traditional CDI Approaches

• Embrace Change in Current CDI Programs- Transform, Redesign, Reposition and Reengineer Present CDI Programs as the Backbone for Achieving Clinical Documentation Excellence
• Outline and Discuss Key Elements of an Effective CDI Program Necessary for Successful Transformation That Creates a Vision That Inspires Physicians, the Care Team and All Relevant Health care Stakeholders to Work Together to Consistently Achieve Clinical Documentation Excellence
• Share Two CDI Program Development Case Studies, Highlighting Operational Processes and Redesign Required as Well as Key Performance Indicators Established and Implemented to Achieve Solid Performance in Clinical Documentation Excellence That Was Sustainable Over Time

Defining Best Practice Standards and Principles of Physician Documentation for Effective Patient Care Communication

• Define Best Practice Standards and Principles of Physician Documentation That Communicates Patient Care Effectively Using Real Case Studies Outlining Insufficient Versus Sufficient Documentation
• How CDI Programs Can Incorporate Best Practice Standards and Principles of Clinical Documentation Into Present Day CDI Programs With a Focus Upon Physician Learnings and Teachings Extending Beyond the Traditional Query Process
• The Physician Advisor as the Leader and Change Agent in Transforming Current CDI Efforts From Reimbursement to Quality and Completeness of Documentation- It Is All About the Patient

Credits

Faculty

Douglas Cutler

Northern Arizona Hospitalists

• Conducts webinars on clinical documentation and its importance to the practicing physician
• Continues to work as a hospitalist in Arizona; has been a regional medical director of a multistate Hospitalist Group as well as physician advisor in Phoenix
• Physician Professional Development: Bridging the gap between the new work reality and self-satisfaction
• Honorable discharge USAF as Major
• Member of the Society of Hospital Medicine and American College of Physician Advisors
• B.S. degree and M.D. degree, University of Michigan, Residency at Wright Patterson USAF Base
• Can be contacted at 623-341-8813 or [email protected]

Glenn Krauss, B.B.A., RHIA, CCS, CCS-P, CPUR, CCDS

• CEP & founder of Core-CDI, co-founder of Top Gun Audit School; Core-CDI.com and TopGunAuditSchool.com
• Creator and host of a monthly podcast titled Wiser Wednesdays- Experience Speaks
• Previously held position as director of clinical documentation improvement at a large Level I Trauma Academic Medical Center in the Southwest
• Practice emphasizes all aspects of reimbursement and revenue cycle processes, including ICD-10 and CPT/evaluation and management coding, clinical documentation improvement, denials management/denial avoidance and physician practice management
• Conducts regular seminars and workshops on numerous areas, including medical necessity establishment from a physician perspective, clinical documentation improvement, denials management, and coding education and training
• Author of several publications related to clinical coding, establishment of medical necessity beyond medicare local coverage determinations, soliciting buy-in from physicians in the rollout of clinical documentation improvement programs, and the role of the clinical documentation improvement specialists beyond improving MS-DRG assignment and resulting financial reimbursement including how CDI can best transform and contribute to a denials avoidance approach to documentation excellence
• Created and managed an active LinkedIn forum titled Physician Documentation Improvement-A New Paradigm intended to provoke thought provocative discussion on anything CDI related
• Certificate in Health Information Management, University of Washington in Seattle
• Member of AHIMA, American College of Physician Advisors, Health Care Financial Management Association, Association for Clinical Documentation Improvement Specialists
• B.B.A. degree in management, Hofstra University in Hempstead, New York
• Can be contacted at 603-303-3337 or [email protected]