Many of the nation’s hospitals now have clinical documentation improvement (CDI), management, or integrity programs. They are designed to help physicians improve the documentation of diagnostic or procedural information in inpatient medical records so that the documentation meets the needs of the coding process. There are good things that can come out of these programs, but there can also be bad things.
As the Patient Protection and Affordable Care Act implementation progresses, the quality and outcomes of care face increasing public scrutiny. Policymakers will determine our complication rates and publicize them on the Internet, influencing public perception of our competencies and quality. Don’t believe me? Read in the Atlanta Journal-Constitution about some Georgia hospitals’ “high” pneumonia, heart failure, and myocardial infarction mortality (http://tinyurl.com/GA-mortality). See your own cost efficiency and quality profile on United Healthcare’s website (www.uhc.com) under the “Find a Physician” tab. Where is information to make these determinations obtained? It’s from ICD-9-CM codes assigned by our hospitals based upon documentation. Consequently, we have a vested interest in ensuring that complication codes are submitted accurately.
Now that fall is in the air, hospitals may feel a chill as Medicare implements the Patient Protection and Affordable Care Act (PPACA) through the 2011 inpatient prospective payment system. Aspects include:
As physicians, we are quite aware of the severity of illness of the cancer patients we treat. However, we frequently are not cognizant of the elements of their diseases that need documentation or clarification in the medical record to accurately portray the complexity of those patients. I’d like to discuss some of the issues that surgeons, oncologists, family physicians, and pediatricians might face that need some attention in documentation.
Despite the numerous jokes on the subject, physician illegibility is no laughing matter, and Kaweah Delta Medical Center knows it. That’s why, after The Joint Commission found problems with the facility’s physician legibility, Kaweah Delta developed a plan to address the problem.
Divisions between HIM and clinical documentation improvement (CDI) staff members are common. But in actuality, everyone needs to work together for the success of the whole. "It's not an us vs. them concept, it's a we concept,"