The Benefits of Clinical Documentation Improvement

Health organizations around the world understand that keeping complex data organized is essential to providing a positive patient experience. In order for patients to have a successful health experience, clinical documentation must be accurately reported. If a patient’s information is not recorded and detailed well, errors will surface and it can deeply affect patients and providers. However, those documentation mistakes can be reduced with clinical documentation improvement (CDI) services. CDI is a process of accurately documenting patient care and communicating that information to other providers. CDI ensures that a patient’s health provider receives correct patient records and information, which will benefit patients and health organizations all the more.

Providing adequate billing practices and positive healthcare encounters are of the utmost importance. Healthcare providers face major issues related to inconsistent billing procedures and insufficient patient payment collections. Professional clinical documentation (CDI) experts assess a health organization’s current medical coding, billing, and payment collection process and provides helpful suggestions to overall improve the healthcare experience. ECLAT Health Solutions is a professional medical billing company that offers quality CDI services to clients including medical billing, coding, and collection procedures. We will determine how providers can increase accuracy, which will provide the many benefits of clinical documentation improvement listed below:  

Reduced Claim Denials

Insurance companies can deny a patient’s request for health care coverage for a variety of reasons. Claims that are illegible, not specific enough, missing information, and not filed on time can lead to insurers refusing to cover patient healthcare services. By utilizing a professional CDI, it will ensure claims are thoroughly completed, easy to understand, and filed on time, which reduces a patient’s claim from being denied.

Decreased Physician Queries

Physicians learn that their language and documentation effects other departments such as reimbursements and quality data. Coders are in charge of reviewing physician notes on a patient and assigning Current Procedural Terminology (CPT®) and International Classification of Diseases (ICD) codes. In cases where the patient documents are illegible, incomplete, conflicting, and unreliable, coders will contact physicians for clarifying documentation. Professional CDI assistance will lessen clinical documentation incompletion, illegibility, and mistakes.

Accurate Coding

Clinical documentation improvement (CDI) will enable physicians to properly input information and complete data into patient records. This will smooth out the healthcare process for other providers that care for the patient and coders too. This allows medical coders to conduct medical reviews of reliable and completed patient documents and treatments and assign codes with precision.

Improved Quality Patient Care

Depending on the amount of staff you have at hand, choosing to implement CDI can be a difficult decision to make. However, when you decide to enforce professional CDI services to certain staff members, it will allow those to focus on what they are good at and will overall reduce documentation mistakes. ECLAT Health Solutions experts provide clinical documentation improvement services that will improve patient records and ensure data correctly reflects the diagnoses and procedures performed.

Better Communication

When patient information is accurately recorded and tracked, it provides a smooth healthcare experience for not only the patient but each individual who requires access to a patient’s health records including billing companies and health care practitioners. Implementing CDI will allow each provider and billing company to be on the same page in regards to the patient’s healthcare, and they will be able to care for them accordingly.

Speak With A Medical Billing & Coding Expert At ECLAT Health Solutions

With ECLAT Health Solutions, our CDI professionals are AAPC certified employees or trained and certified by the American Health Management Association (AHIMA). As a medical billing and coding company, we will provide efficient medical coding and billing services that are precise and will improve health organizations from the ground up. With careful assessments of a client’s current billing and coding procedures, we will produce suggestions as well as quality resources to help clients receive the best CDI service possible.

Contact us at (703) 665-4499 and speak with an ELCAT expert today!

Webinar Roundup: Exploring Respiratory Failure from a Clinical Perspective

As revenue cycle management, medical coding, and clinical documentation improvement professionals, the topic of acute and chronic respiratory failure is something that comes across our clients’ screens regularly. It is a very unique health issue that many don’t fully understand, and that can be difficult to document. Because of its distinctive properties, and popular audience request, we felt it was a topic that needed some discussion. That is why we chose this quarter’s webinar topic from our “Experience the Brilliance” webinar series to explore respiratory failure from a clinical perspective. Joined by ECLAT’s Senior Director of Coding and HIM Operations, Marie Thomas, and clinical care physician, Krishna Thandra, MD, we discussed the basics of respiratory failure, how it is viewed from a clinical perspective, and how to identify and document it from a medical coding perspective.

2018-07-31 13.00 Exploring Respiratory Failure – A Clinical Perspective from Giovanna Govea on Vimeo.

Exploring Respiratory Failure – A Clinical Perspective from Giovanna Govea on Vimeo.

The Clinical Perspective

First, the MC of the webinar, Giovanna Govea of ECLAT Health Solutions, defined respiratory failure before introducing Dr. Krishna Thandra to offer a clinical perspective. According to the late Robert S. Gold, MD, “respiratory failure basically means that the lungs cannot meet the needs of the body to supply oxygen and remove carbon dioxide.” In clinical trials, signs of respiratory failure include increased respiratory rate, increased burden of oxygen, decreased oxygen levels, and increased carbon dioxide levels.

When someone experiences respiratory failure, there are some key physiological changes that occur:

  1. Impacts the heart because of the lower oxygen level
  2. Cor pulmonale may occur with right sided heart enlargement
  3. Liver may become enlarged/engorged, swelling of LE or UE, irregular rhythm
  4. Risk of blood clots

As Dr. Thandra discussed,

The Medical Coding Perspective

Identifying respiratory failure quickly and properly is imperative to a patient’s health. After respiratory failure is identified by a physician, the clinical documentation is the next important step in the process. The clinical perspective helps us to better distinguish clinical criteria for acute vs. chronic respiratory failure, and to identify the correct medical coding assignment for respiratory failure cases. There are 3 important sets of criteria for identifying acute respiratory failure, as outlined in the webinar by Marie Thomas, Senior Director of Coding and HIM Operations, all of which can be found on pages 7-9 of the webinar handout. It is important to look closely at these criteria, as some distinctions are vital to identify in order to document the condition properly.

What happens if a patient is admitted with respiratory failure and another acute condition? The principal diagnosis depends on the individual patient’s situation and what caused the admission of the patient to the hospital. This coding guideline applies regardless of whether the other acute condition is a respiratory or non-respiratory condition. If the documentation is unclear, the physician should clarify which of the two conditions was the reason for admission. In some cases, both conditions may be equally responsible for the admission, just make sure that the severity of illness and intensity of service are equivalent for both.

Case Study and Poll

After reviewing respiratory failure from clinical and coding perspectives, Marie walked the webinar attendees through a case study followed by a question. To view the case study and see if the audience answered correctly, be sure to watch the webinar replay and review the webinar handout. Feel free to let us know what you think the answer is by commenting below.

Join Us for Future Segments of “Experience the Brilliance” Free Webinar Series

Our “Experience the Brilliance” Webinar Series is meant to provide educational insight to medical coders, CDI professionals, and HIM professionals for FREE on a quarterly basis, so be sure to join us next time! Follow ECLAT on LinkedIn for updates on future webinars and industry-related news.

Clinical Documentation Plays A Crucial Role in the Revenue Cycle

Clinical documentation improvement (CDI) is becoming increasingly valuable in today’s healthcare world. CDI’s relevance is supported by AHIMA’s newly-released a CDI outpatient toolkit. This toolkit equips providers with the guidance they need to establish their own CDI system. Toolkits like this paired with professional clinical documentation improvement services help providers review their documentation processes and identify opportunities for improvement.

Clinical documentation touches all parts of the revenue cycle. No matter how skilled a facility’s staff of coders is, if the clinical documentation has gaps, the coders may end up assigning the wrong code—which will ultimately lead to a denial. Claims denials can leave millions of dollars of revenue on the table each year. Further, accurate clinical documentation not only affects providers’ back-end, but their patients as well. From the forms patients fill out at sign-in to the bill they receive at the end of their visit, any erroneous documents may lead to them paying more, misunderstanding their treatment or charges, and compromise their good relationship with the provider.

All around, providers looking to foster a healthier revenue cycle should consider partnering with expert CDI service providers. ECLAT Health Solutions’ CDI services help our clients understand weak spots in their current documentation processes and identify opportunities for improvement. We help them earn a variety of benefits for their practice:

 

The Benefits of Clinical Documentation Improvement

Perhaps the most appealing benefit of CDI services is the potential for increased revenue. In a Black Book Market Research report, hospitals with 150+ beds who outsourced CDI made over $1.5 million in revenue after hiring CDI services. This increased revenue comes, of course, from CDI specialists fixing providers’ current documentation issues, which means more accurate coding and appropriate reimbursements. Additionally, much of this revenue increase occurs because CDI specialists can also identify more efficient documentation practices to prevent future errors.

Some practices looking to implement CDI, however, may struggle to find enough already stretched-thin staff to take on CDI responsibilities. This is where partnering with a CDI company comes in. Providers who choose professional CDI services will free up many of their staff to focus on what they do best: ensure the practice keeps operating smoothly. The less staff struggling to fix documentation errors, the more staff members are available to focus on daily operations, and/or other areas that need improvement such as billing, patient care and staff communication. Naturally, these also play their part to improve revenue. However, a crucial benefit of smoother operations is less-stressed staff, fewer mistakes being made, and happier patients.

 

All in all, taking the time to implement CDI will help practices earn more revenue, enjoy fewer coding mistakes, improve patient care, and streamline daily operations. Finding the staff to do this in-house can be a challenge, making choosing a healthcare solutions company the best option for the best results. ECLAT Health Solutions helps our clients earn these benefits and more with our CDI services. Our CDI experts are skilled at identifying documentation errors and making clear, concrete suggestions to remedy these errors. We are happy to provide our clients with what we call the ECLAT Advantage which includes ongoing support, and more.