Clinical documentation improvement (CDI) programs are prevalent in many hospitals and have evolved over the years. In 2014, 66% of 318 hospitals surveyed by AHIMA had a CDI program in place. If all surveyed facilities that planned to implement a CDI program did so, 80% of responding hospitals would have one. These numbers are likely even higher today as CDI programs become ever more relevant.
CDI programs can be a valuable bridge between clinical care and coding at hospitals. By concurrently reviewing clinical documentation in medical records and conferring with and educating providers, CDI teams continually support accurate documentation. When CDI program staff collaborate with providers and coders around improved documentation, the result is more accurate coding, reporting, quality metrics, and reimbursement.
Greater detail in clinical documentation is required since the introduction of ICD-10, making CDI efforts even more relevant. In addition, healthcare is steadily moving toward value-based purchasing and greater scrutiny from regulators and the public. With all of this in mind, it is more important than ever to get documentation and coding right. The daily activities surrounding CDI are crucial to successful outcomes and sustainability of facilities and healthcare systems.
The 2016 OPPS final rule includes the first negative payment update for the system. CMS finalized its proposal to reduce the conversion factor by 2% to account for its overestimation of dollars for packaged labs built into the 2014 APC rates, despite congressional and provider pressure to not proceed with this payment reduction.
When the Quality Improvement Organizations (QIO) took over the role of education and enforcement for the 2-midnight rule on October 1, 2015, many anticipated that their reviews would only look at records from that date forward. But in an unpleasant turn of events, some hospitals have reported QIO records requests zeroing in on cases as far back as May 2015.
On November 16, 2015, CMS released a final rule that bundles acute-care payments for knee and hip replacement surgeries, the most common type of inpatient surgeries for Medicare beneficiaries, with some 400,000 performed in 2004.
Clinical documentation improvement specialists and case managers share a common goal but often aren't on the same page when it comes to improving documentation within the hospital.
Perhaps recognizing the massive undertaking for coding and HIM departments in 2015 with the implementation of ICD-10, the latest CPT® update includes a relatively small 367 changes for 2016.
