Clinical Documentation Improvement
|
|
- Tracey Hensley
- 5 years ago
- Views:
Transcription
1 Clinical Documentation Improvement Precise Terminology is the Key to Supporting the Integrity of Documentation # Rev. 10/16
2 Specific Documentation Support medical necessity Capture severity and complexity of illness Validate the length of stay Support CMI (case mix index) compensation Withstand auditing Accurately reflect quality indicators and publicly published outcome measures 2
3 Coding the Medical Record The primary diagnosis, responsible for occasioning the admission, must be noted by the attending Physician. Any diagnosis that is clinically supported and currently being treated, monitored or evaluated can be coded. Diagnoses discovered by diagnostic testing must be validated as clinically significant in progress notes by an actively involved practitioner. 3
4 Codes For Capture Documents to code from ER Physicians note H & P MD, PA, ARNP progress note MD Consultation Operative or Procedure report Discharge Summary Supporting evidence Nursing note PT/OT/RT/Dietary note Lab results X-ray/CT/MRI/ECHO Pathology report Flow sheet 4
5 CDIs Role in Chart Completion Concurrently review the entire in-patient chart, usually by day 3-4 of hospital admission Seek to clarify any documentation that is unspecified, unclear, conflicting or missing Send Queries to providers to obtain any additional clarifying documentation 5
6 The Query Process A Query is an electronic question posed to a provider by a CDI RN or MD Most queries are derived from a template bank and are always in a multiple choice format All queries are meant to be non-leading and the best judgment of the practitioner is advised Once answered, the query becomes a permanent part of the medical record 6
7 Answering The Query If a query is sent it will populate in the Epic in-basket for chart completion A query that is sent on a template can be answered in just a few clicks Select a response from the drop down menu of options or manually fill in the appropriate response as needed A signed query becomes a progress note 7
8
9 What if I Don t Answer? CDI personnel are required to follow-up on any query sent after 24 hours and every 24 hours thereafter. This can be done through , text, page, office messages or personally After 72 hours an escalation process is initiated to facilitate compliance CDI personnel are located on each campus M-F to provide assistance or answer questions 9
10 Hospital Acquired Conditions (HAC) and Patient Safety Indicators ( PSI) Foreign object retained after surgery Air embolism Blood incompatibility Pressure ulcers Falls Manifestations of poor glycemic control Catheter-associated urinary tract infection Vascular catheter-associated infection DVT/ pulmonary embolism after lower extremity procedures Surgical site infection Post operative DVT/PE, Respiratory Failure & Sepsis If you are not able to determine present on admission status- unable to determine choice does not code to a HAC
11 Principal Diagnosis Secondary Diagnoses COPD Observer A Observer B Observer C COPD Exacerbation w/o CC/MCC COPD Exacerbation w/cc Chronic Diastolic/Systolic CHF Oral Lasix -chronic home medication Medicare DRG MS-DRG AMLOS COPD Exacerbation Relative Weights Severity of Illness Risk of Mortality Level 1/minor Level 1/minor Level 2/moderate Level 2/moderate w/mcc Acute Diastolic/Systolic CHF IV Lasix Level 2/moderate Level 2/moderate Reimbursement $5, $6, $7,647.09
12 Pneumonia Specificity Pneumonia can be specified based on the treatment. Negative or inconclusive sputum cultures do not preclude a diagnosis of a specific bacterial pneumonia in patients with the clinical evidence of this condition. (per: AHA Coding Clinic). If you are/were treating a suspected, possible or probable gram negative or other resistant pneumonia or Sepsis, please document as such. CAP and HCAP are not specified 12
13 Pneumonia Principal Diagnosis Secondary Diagnoses Observer A Observer B Observer C Observer D Simple Pneumonia, unspecified Simple Pneumonia, unspecified Simple Pneumonia, unspecified Complex Pneumonia: Treating Gram Negative w/o CC/MCC w/cc AKI w/mcc ARF w/mcc ARF Medicare DRG MS-DRG AMLOS Relative Weights Severity of Illness Risk of Mortality Level 1/minor Level 1/minor Level 2/mod Level 1/minor Level 3/major Level 3/major Level 3/major Level 3/major Reimbursement $5, $6, $9, $12,023.79
14 Diagnoses Impact Metrics Diagnosis CMI SOI/ROM ALOS Weakness Glioblastoma grade 4 AKI Glioblastoma grade 4 AKI Cerebral edema / /
15 Hierarchical Condition Category For Risk Adjustment Reimbursement model implemented by CMS HCC diagnoses are considered excellent predictors of risk for future healthcare needs Documenting the entire disease burden during every 12-month period is essential for capturing resource consumption Common HCC diagnoses include: Protein Calorie Malnutrition Specified Bacterial Pneumonia Diabetes with complications Drug and Alcohol Dependence Specified (Systolic/Diastolic) CHF 15
16 Navigating Change CDI is a resource team that works in collaboration with providers to ensure that the documentation accurately encompasses all aspects of the medical picture and captures the level of care needed to help each patient Quality measures that affect population health, risk of mortality and morbidity are becoming a vital part of the health record. Diagnoses such as Malnutrition and Obesity are sought out to help define appropriate medical care in compliance with CMS guidelines.. 16
17 What has changed since the implementation of ICD-10: Diagnoses Codes: 14,025 71,486 Procedure Codes: 3,824 75,625 Body System Body Part Device Section Root Operation Approach Qualifier
18 Injury codes increased from 2,600 to 43,000 Top 5 Most Bizarre ICD-10 codes of W55.21 Bitten by a cow 2. Z63.1 Problems in relationship with in-laws 3.W56.22 Struck by Orca, initial encounter 4.V97.33 Sucked into jet engine 5.V91.07 Burn due to water-skis on fire Any Questions? 18
Clinical Documentation: Beyond The Financials Cheryll A. Rogers, RHIA, CDIP, CCDS, CCS Senior Inpatient Consultant 3M HIS Consulting Services
Clinical Documentation: Beyond The Financials Cheryll A. Rogers, RHIA, CDIP, CCDS, CCS Senior Inpatient Consultant 3M HIS Consulting Services Clinical Documentation: Beyond The Financials Key Points of
More informationClinical Documentation Improvement at UIHC
Clinical Documentation Improvement at UIHC Deanna Brennan, RN BSN Quality & Operations Improvement Manager/Director Clinical Documentation Improvement 1 Clinical Documentation Improvement Clinical Documentation
More informationWhat is CDI? 2016 HTH FL Boot Camp. HIM/Documentation: Endurance in the Clinical Documentation Improvement (CDI) Race
HIM/Documentation: Endurance in the Clinical Documentation Improvement (CDI) Race Presented By: Sandy Sage Developed by Annie Lee Sallee Endurance in the Clinical Documentation Improvement (CDI) Race Learning
More informationDisclosure of Proprietary Interest
HomeTown Health HCCS Hospital Consortium Project: Track 3- Clinical Documentation: Strategies for Sharpening Focus Jenan Custer RHIT, CCS, CPC, CDIP AHIMA Approved ICD-10-CM/PCS Trainer Director of Coding
More informationClinical Documentation Improvement (CDI) Programs: What Role Should Compliance Play?
Clinical Documentation Improvement (CDI) Programs: What Role Should Compliance Play? June 17, 2016 Agenda Clinical Documentation Improvement (CDI) Perspective An Effective CDI Program Core Focus: Compliance
More informationHospital Clinical Documentation Improvement
Hospital Clinical Documentation Improvement March 2016 Clinical Documentation Improvement (CDI) is a team approach to improving documentation practices through ongoing education, concurrent chart review
More informationHomeTown Health HCCS. Hospital Consortium Project: Track 1 Nuts and Bolts of: CDI Proficiencies
HomeTown Health HCCS Hospital Consortium Project: Track 1 Nuts and Bolts of: CDI Proficiencies Jenan Custer RHIT, CCS, CPC, CDIP AHIMA Approved ICD 10 CM/PCS Trainer Director of Coding Healthcare Coding
More informationA Guide to CDI. AAPC National Conference Salud! HEALTHCARE SOLUTIONS
A Guide to CDI AAPC National Conference 2013 Salud! HEALTHCARE SOLUTIONS Let patient centric, patient driven, patient quality of care guide needs Objectives Identify the Purpose of an effective CDI program
More informationEssentials for Clinical Documentation Integrity 2017
Essentials for Clinical Documentation Integrity 2017 Prepared and Published By: MedLearn Publishing A Division of Panacea Healthcare Solutions, Inc. 287 East Sixth Street, Suite 400 St. Paul, MN 55101
More informationCompliance Objectives
Eyeing Coding Compliance and CDI Compliance Programs What Compliance Officers Need to Know or Should Know By Diana Adams, RHIA (adamsrra@tx.rr.com) Compliance Objectives Discovering who are the healthcare
More informationPolling Question #1. Denials and CDI: A Recovery Auditor s Perspective
1 Denials and CDI: A Recovery Auditor s Perspective Tim Garrett, MD Medical Director Barb Brant, RN, CCDS, CDIP, CCS Sr. Clinical Trainer/DRG Auditors Cotiviti, Atlanta, GA 2 Polling Question #1 Does inpatient
More informationHealth Economics: Medicare and Medicaid Hospital Reimbursement
Health Economics: Medicare and Medicaid Hospital Reimbursement Jacobi Medical Center Noon Conference Feb 14, 2011 Colin D. Cha Fong Goals Brief introduction to Medicare and Medicaid How the hospital is
More informationUW MEDICINE ICD-10 Program UW MEDICINE ICD-10
UW MEDICINE ICD-10 Program UW MEDICINE ICD-10 There and back again INTEGRATION OF MANDATES ACO Quality Based Reimbursement Meaningful Use, P4P, etc. ICD-10 HIPAA, 5010 2 STRATEGIC OPPORTUNITIES Significant
More informationClinical Documentation Improvement: Best Practice
Revenue Cycle Solutions Consulting and Management Services Clinical Documentation Improvement: Best Practice Our mission: To help you finance yours. 2 Managing Your Audio Use Telephone Use Microphone and
More informationCMS Quality Program- Outcome Measures. Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: December 2015 Revised: January 2018
CMS Quality Program- Outcome Measures Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: December 2015 Revised: January 2018 Philosophy The Centers for Medicare and Medicaid Services (CMS) is changing
More informationRAC Targets, Bullseyes and Near Misses: What Your CDI Program Should Know
RAC Targets, Bullseyes and Near Misses: What Your CDI Program Should Know Barbara Flynn, RHIA, CCS, Certified AHIMA ICD-10-CM/PCS Trainer, ICD10 Ambassador Vice President for Health Information Management
More informationLearning Objectives. Denver Health Medical Center. Complex Coding Scenarios and Resolution
Complex Coding Scenarios and Resolution Eric Ryland, MS, RHIA, CCDS, CHDA, CCS, CPC Manager of Coding Denver Health Medical Center Denver, Colo. 2 Learning Objectives Denver Health Medical Center Evaluate
More informationReimbursement Policy Subject: Present on Admission Indicator for Health Care-Acquired Conditions 01/01/14 Administration 05/02/16
Anthem BlueCross BlueShield Medicaid Reimbursement Policy Subject: Committee Approval Obtained: Effective Date: 01/01/14 Section: Administration 05/02/16 ***** The most current version of our reimbursement
More informationThe 5 W s of the CMS Core Quality Process and Outcome Measures
The 5 W s of the CMS Core Quality Process and Outcome Measures Understanding the process and the expectations Developed by Kathy Wonderly RN,BSPA, CPHQ Performance Improvement Coordinator Developed : September
More informationAugust 1, 2012 (202) CMS makes changes to improve quality of care during hospital inpatient stays
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Room 352-G 200 Independence Avenue, SW Washington, DC 20201 FACT SHEET FOR IMMEDIATE RELEASE Contact: CMS Media Relations
More informationPhysician Partners for CDI: Strategies for Goal Alignment. 7th Annual Association for Clinical Documentation Improvement Specialists Conference
7th Annual Association for Clinical Documentation Improvement Specialists Conference Physician Partners for CDI: Strategies for Goal Alignment Larry Weems II, MD Medical Director Novant Health Huntersville
More information(1) Provides a brief overview of CMS Medicare payment policy for selected HACs;
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 Center for Medicaid and State Operations SMDL #08-004
More informationValue of the CDI Program Cindy Dennis, MHS, RHIT
Improving Reimbursement through Clinical Documentation: A New Beginning June 28, 2013 Presented by Salem Health: Cindy Dennis, MHS, RHIT Coleen Elser, RN, CCDS, CDS Linda Dawson, RHIT Judy Parker, RHIT,
More informationValue of the CDI Program Cindy Dennis, MHS, RHIT
Improving Reimbursement through Clinical Documentation: A New Beginning June 28, 2013 Presented by Salem Health: Cindy Dennis, MHS, RHIT Coleen Elser, RN, CCDS, CDS Linda Dawson, RHIT Judy Parker, RHIT,
More informationEmerging Outpatient CDI Drivers and Technologies
7th Annual Association for Clinical Documentation Improvement Specialists Conference Emerging Outpatient CDI Drivers and Technologies Elaine King, MHS, RHIA, CHP, CHDA, CDIP, FAHIMA Outpatient Payment
More informationQuality Reporting in the Public Domain
Quality Reporting in the Public Domain Disclaimer This material is designed and provided to communicate information about inpatient coding, clinical documentation, and/or compliance in an educational format
More informationValue-Based Purchasing & Payment Reform How Will It Affect You?
Value-Based Purchasing & Payment Reform How Will It Affect You? HFAP Webinar September 21, 2012 Nell Buhlman, MBA VP, Product Strategy Click to view recording. Agenda Payment Reform Landscape Current &
More informationUI Health Hospital Dashboard September 7, 2017
UI Health Hospital Dashboard September 20 September 7, 20 UI Health Metrics FY Q4 Actual FY Q4 Target FY Q4 Actual 4th Quarter % change FY vs FY Discharges 4,558 4,680 4,720 Combined Observation Cases
More informationReimbursement Policy Subject: Present on Admission Indicator for Health Care-Acquired Conditions 06/01/12 05/02/16 Administration Policy
Reimbursement Policy Subject: Present on Admission Indicator for Health Care-Acquired Conditions Committee Approval Obtained: Section: Effective Date: 06/01/12 05/02/16 Administration *****The most current
More informationP4P Programs 9/13/2013. Medicare P4P Programs. Medicaid P4P Programs
P4P Programs Medicare P4P Programs Hospital Quality Reporting Programs (IQR and OQR) Hospital Value-Based Purchasing (VBP) Program Hospital Readmissions Reduction Program (HRRP) Hospital-Acquired Conditions
More informationLearning Objectives. CDI Counts: Metrics for the CDI Professional. At the completion of this educational activity, the learner will be able to:
1 CDI Counts: Metrics for the CDI Professional Rani Stoddard, MBA, RN, RHIT, CPHQ, CPHQ, RHIT, CCDS, C CDI CDI Supervisor Henry Mayo Newhall Hospital Valencia, CA Learning Objectives At the completion
More informationCompliance Objectives
What Compliance Officers Need to Know or Should Know under Auditing and Monitoring Guideline-Avoiding Headaches By Diana Adams, RHIA (adamsrra@tx.rr.com)-2017 Compliance Objectives Discovering who are
More informationCompliance Objectives
Eyeing Coding Compliance and CDI Compliance Programs What Compliance Officers Need to Know or Should Know By Diana Adams, RHIA (adamsrra@tx.rr.com) Compliance Objectives Discovering who are the healthcare
More informationHospital Acquired Conditions: using ACS-NSQIP to drive performance. J Michael Henderson Jackie Matthews Nirav Vakharia
Hospital Acquired Conditions: using ACS-NSQIP to drive performance J Michael Henderson Jackie Matthews Nirav Vakharia Your Team: Quality & Patient Safety Institute Cleveland Clinic Mike Henderson: Chief
More informationDocumentation 101: CDI JULY 19, 2017
Documentation 101: CDI THE FIFTH NATIONAL PHYSICIAN ADVISOR AND UTILIZATION REVIEW BOOT CAMP JULY 19, 2017 Infirmary Health: About Us Infirmary Health is the largest non-governmental healthcare system
More informationDescribe the process for implementing an OP CDI program
1 Outpatient CDI: The Marriage of MACRA and HCCs Marion Kruse, RN, MBA Founding Partner LYM Consulting Columbus, OH Learning Objectives At the completion of this educational activity, the learner will
More informationMedicare s Inpatient Final Rule for Claire Kapilow, Director, Regulatory Affairs
Medicare s Inpatient Final Rule for 2013 Claire Kapilow, Director, Regulatory Affairs Publisher Notice Although we have tried to include accurate and comprehensive information in this presentation, please
More information2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
To Err Is Human: CDI Impact on Patient Safety Indicators Kathleen Shindle, RN, BSN, CCDS, CDIP Allison Clerval, RN, BSN, CCDS, CDIP Clinical Supervisors Thomas Jefferson University Hospital Philadelphia,
More informationMedicare Value Based Purchasing August 14, 2012
Medicare Value Based Purchasing August 14, 2012 Wes Champion Senior Vice President Premier Performance Partners Copyright 2012 PREMIER INC, ALL RIGHTS RESERVED Premier is the nation s largest healthcare
More information2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
The Afterlife: Mortality in the Post Apocalyptic World of ICD 10 Debbie Malick, RN, BSN, MBA, CNML Clinical Nurse Specialist Cone Health at Alamance Regional Medical Center Burlington, NC 1 Background
More informationGeneral Background of CDI
Clinical Documentation Improvement The Physician Champion ILHIMA 04/30/16 1 General Background of CDI 2 1 CMS Federal Register August 2008 Final Rule (CMS-1533-FC page 208) We do not believe there is anything
More informationThe dawn of hospital pay for quality has arrived. Hospitals have been reporting
Value-based purchasing SCIP measures to weigh in Medicare pay starting in 2013 The dawn of hospital pay for quality has arrived. Hospitals have been reporting Surgical Care Improvement Project (SCIP) measures
More informationCommunity Health Needs Assessment Mercy Hospital Ardmore 2012
Community Health Needs Assessment Mercy Hospital Ardmore 2012 Contents Table of Contents Introduction... 2 Description and Basic Community Demographics... 2 Who was Involved in Assessment?... 2 Community
More informationImprove Your Revenue for the Services Your Provide with Proper Coding and Documentation. by Christina Rock, BSN, RN Supervisor, Clinical Education
Improve Your Revenue for the Services Your Provide with Proper Coding and Documentation by Christina Rock, BSN, RN Supervisor, Clinical Education Objectives Awareness of resources and reference materials
More informationReimbursement Policy Subject: Present on Admission Indicator for Health Care-Acquired Conditions 04/01/14 Administration 05/02/16
Reimbursement Policy Subject: Present on Admission Indicator for Health Care-Acquired Conditions Committee Approval Obtained: Effective Date: 04/01/14 Section: Administration 05/02/16 ***** The most current
More informationOverview of Final Rule for FY 2011 Revisions to the Medicare Hospital Inpatient Prospective Payment System
Overview of Final Rule for FY 2011 Revisions to the Medicare Hospital Inpatient Prospective Payment System The final rule regarding fiscal year (FY) 2011 revisions to the Medicare hospital inpatient prospective
More informationClinical Documentation Improvement
Clinical Documentation Improvement Measures, Models, and Multi-facilities Patty Dietz RN, BSN, CPHQ Midas+ Solutions Consultant Sara Wagner MHA Business Analyst The Ohio State University Wexner Medical
More information3/21/2018. Foundation Management Services, Inc All rights reserved. Unauthorized reproduction is strictly prohibited.
Keys to Documentation Success in Home Health Coding DISCLAIMER This material is designed and provided to communicate information about compliance, ethics and coding in an educational format and manner.
More informationThe Nexus of Quality and Finance
The Nexus of Quality and Finance Kristen Geissler Pat Ercolano March 4, 2014 Transition from Volume to Value: IHI Triple Aim IHI Triple Aim Improve patient experience of care (quality & satisfaction) Improve
More informationCME Disclosure. HCAHPS- Hardwiring Your Hospital for Pay-for-Performance Success. Accreditation Statement. Designation of Credit.
CME Disclosure Accreditation Statement Studer Group is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Designation
More informationRisk Adjustment Medicare and Commercial
Risk Adjustment Medicare and Commercial 900 1671 0416 Transform your thinking about Introduction In a time of continual regulatory reform and the evolution of payer/provider reimbursement models, are you
More informationPerformance Payment: Never Pay for Never Events: Including Readmissions in Medicare s s (non-payment for) Hospital Acquired Conditions Policy
Performance Payment: Never Pay for Never Events: Including Readmissions in Medicare s s (non-payment for) Hospital Acquired Conditions Policy Peter McNair and Hal Luft Palo Alto Medical Foundation Research
More informationScoring Methodology FALL 2016
Scoring Methodology FALL 2016 CONTENTS What is the Hospital Safety Grade?... 4 Eligible Hospitals... 4 Measures... 5 Measure Descriptions... 7 Process/Structural Measures... 7 Computerized Physician Order
More informationDisclosure of Proprietary Interest. HomeTown Health HCCS
HomeTown Health HCCS Hospital Consortium Project: Track 2 Clinical Documentation Program: E ssentials and Took Kits Jenan Custer RHIT, CCS, CPC, CDIP AHIMA Approved ICD-10-CM/PCS Trainer Director of Coding
More informationThe ins and outs of CDE 10 steps for addressing clinical documentation excellence
The ins and outs of CDE 10 steps for addressing clinical documentation excellence What s at stake for CDE outpatient/inpatient integration? Historically, provider organizations have focused their clinical
More informationUNIVERSITY OF ILLINOIS HOSPITAL & HEALTH SCIENCES SYSTEM HOSPITAL DASHBOARD
UNIVERSITY OF ILLINOIS HOSPITAL & HEALTH SCIENCES SYSTEM HOSPITAL DASHBOARD January 19, 2017 UI Health Metrics FY17 Q1 Actual FY17 Q1 Target FY Q1 Actual Ist Quarter % change FY17 vs FY Discharges 4,836
More informationAddressing and clarifying 2017 Guideline recommendations
Addressing and clarifying 2017 Guideline recommendations WHITE PAPER z FEATURES Supportive documentation..2 Tipping the scales... 3 Reminders... 3 Additional changes... 4 PCS concerns... 5 Sepsis... 7
More informationRisk Adjusted Diagnosis Coding:
Risk Adjusted Diagnosis Coding: Reporting ChronicDisease for Population Health Management Jeri Leong, R.N., CPC, CPC-H, CPMA, CPC-I Executive Director 1 Learning Objectives Explain the concept Medicare
More informationEffective Tools to Prevent and Manage Adverse Events
Effective Tools to Prevent and Manage Adverse Events Based on Office of Inspector General Adverse Events Report Diane C. Vaughn, RN, C-DONA/LTC; LNHA vaughndiane@hotmail.com Objectives Upon completion
More information2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Potentially Preventable Complications: Getting the Whole Picture Cheryl Manchenton, RN, BSN, CCDS Project Manager/Quality Services Lead 3M HIS Consulting Services Atlanta, GA 1 Learning Objectives At the
More informationMedicare P4P -- Medicare Quality Reporting, Incentive and Penalty Programs
Medicare P4P -- Medicare Quality Reporting, Incentive and Penalty Programs Presenter: Daniel J. Hettich King & Spalding; Washington, DC dhettich@kslaw.com 1 I. Introduction Evolution of Medicare as a Purchaser
More informationIt's All in the Claims Data! Observed to Expected Ratio & Risk Adjusted Rates Explained
It's All in the Claims Data! Observed to Expected Ratio & Risk Adjusted Rates Explained Faisal Hussain, MD, CCDS, CDIP, CCS* Corporate Director, CDI CHSPSC, LLC Franklin, TN Beth Ming, BSN, RN, CCDS Consultant,
More informationProvider Preventable Conditions: Health Care Acquired Conditions and Present on Admission Policy
Provider Preventable Conditions: Health Care Acquired Conditions and Present on Admission Policy Policy Number 2018F7002A Annual Approval Date 3/14/2018 Approved By Reimbursement Policy Oversight Committee
More informationCARING & CODING FOR MALNUTRITION
CARING & CODING FOR MAL Sandy Routhier RHIA, CCS, CDIP, AHIMA Approved ICD-10CM/PCS Trainer CloudMed Solutions Michelle Mathura, RDN, LRD, CDE Director, Nutrition Division DM&A Our Presenters Sandra Routhier,
More informationDischarge checklist and follow-up phone calls: the foundation to an effective discharge process
Discharge checklist and follow-up phone calls: the foundation to an effective discharge process Shari Aman, BSN, RN, MBA, CPHQ Denise Andrews, MBA Stephanie Storie, BSN, RN, CMSRN Deb Nation, RN, CMSRN
More informationOUTPATIENT DOCUMENTATION IMPROVEMENT
OUTPATIENT DOCUMENTATION IMPROVEMENT Pam Brooks, MHA, COC, PCS, CPC Coding Manager Wentworth-Douglass Hospital Dover NH Disclaimer This presentation is for general education purposes only. The information
More informationUnderstanding HSCRC Quality Programs and Methodology Updates
Understanding HSCRC Quality Programs and Methodology Updates Kristen Geissler, MS, PT, CPHQ, MBA Managing Director Beth Greskovich - Director Berkeley Research Group August 19, 2016 Maryland Waiver and
More informationPre-Bill Auditing: The Next ICD-10 Hot Button Issue. Presentation Objectives
Pre-Bill Auditing: The Next ICD-10 Hot Button Issue Featuring Kimberly J. Carr RHIT, CCS, CDIP, CCDS, AHIMA-Approved ICD-10 CM/PCS Trainer Jonathan LaFleur, BSN, RN, CCS 1 Presentation Objectives Define
More informationClinical Operations. Kelvin A. Baggett, M.D., M.P.H., M.B.A. SVP, Clinical Operations & Chief Medical Officer December 10, 2012
Clinical Operations Kelvin A. Baggett, M.D., M.P.H., M.B.A. SVP, Clinical Operations & Chief Medical Officer December 10, 2012 Forward-looking Statements Certain statements contained in this presentation
More informationAnalysis of Final Rule for FY 2009 Revisions to the Medicare Hospital Inpatient Prospective Payment System
Analysis of Final Rule for FY 2009 Revisions to the Medicare Hospital Inpatient Prospective Payment System The final rule regarding fiscal year (FY) 2009 revisions to the Medicare hospital inpatient prospective
More informationScoring Methodology FALL 2017
Scoring Methodology FALL 2017 CONTENTS What is the Hospital Safety Grade?... 4 Eligible Hospitals... 4 Measures... 5 Measure Descriptions... 9 Process/Structural Measures... 9 Computerized Physician Order
More informationSuccesses in Nutrition Support: Malnutrition Initiative
Successes in Nutrition Support: Malnutrition Initiative Robert DeChicco MS, RD, LD, CNSC Manager, Nutrition Support Team Cleveland Clinic, Cleveland, OH June 2, 2017 Learning Objectives List major milestones
More informationReadmission Program. Objectives. Todays Inspiration 9/17/2018. Kristi Sidel MHA, BSN, RN Director of Quality Initiatives
The In s and Out s of the CMS Readmission Program Kristi Sidel MHA, BSN, RN Director of Quality Initiatives Objectives General overview of the Hospital Readmission Reductions Program Description of measures
More informationUnmet Medical Product Needs Trends & Opportunities
Unmet Medical Product Needs Trends & Opportunities Medical Development Group www.meddevgroup.com November 5, 2008 Presented by Thomas Forest Farb Estabrook Ventures, LLC www.estabrookventures.com tfarb@estabrookventures.com
More information(202) or CMS Proposals to Improve Quality of Care during Hospital Inpatient Stays
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Room 352-G 200 Independence Avenue, SW Washington, DC 20201 FACT SHEET FOR IMMEDIATE RELEASE April 30, 2014 Contact: CMS Media
More informationUniversity of Illinois Hospital and Clinics Dashboard May 2018
May 17, 2018 University of Illinois Hospital and Clinics Dashboard May 2018 Combined Discharges and Observation Cases for the nine months ending March 2018 are 1.6% below budget and 4.9% lower than last
More informationBellagio, Las Vegas November 26-28, 2012 Claire Kapilow, Director, Regulatory Affairs Medicare s Inpatient Final Rule for 2013
Bellagio, Las Vegas November 26-28, 2012 Claire Kapilow, Director, Regulatory Affairs Medicare s Inpatient Final Rule for 2013 Scan this image for a copy of this presentation to load to your QR enabled
More informationUNIVERSITY OF ILLINOIS HOSPITAL & HEALTH SCIENCES SYSTEM HOSPITAL DASHBOARD
September 8, 20 UNIVERSITY OF ILLINOIS HOSPITAL & HEALTH SCIENCES SYSTEM HOSPITAL DASHBOARD UI Health Metrics FY Q4 Actual FY Q4 Target FY Q4 Actual 4th Quarter % change FY vs FY Average Daily Census (ADC)
More informationCMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents Phase 2--Payment Model
CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents Phase 2--Payment Model The Revolving Door One fourth of all nursing home resident go the hospital each year - Some many
More informationNational Patient Safety Goals & Quality Measures CY 2017
National Patient Safety Goals & Quality Measures CY 2017 General Clinical Orientation 2017 January National Patient Safety Goals 1. Identify Patients Correctly 2. Improve Staff Communication 3. Use Medications
More informationTHE IMPACT OF MS-DRGs ON THE ACUTE HEALTHCARE PROVIDER. Dynamics and reform of the Diagnostic Related Grouping (DRG) System
THE IMPACT OF MS-DRGs ON THE ACUTE HEALTHCARE PROVIDER 1st Quarter FY 2007 CMS-DRGs compared to 1st Quarter FY 2008 MS-DRGs American Health Lawyers Association April 10, 2008 Steven L. Robinson, RN, PA-O,
More informationImpact of Risk Scoring And Attribution October 2017 Linda Gates-Striby
STRATEGIC CODING IN THE ERA OF MACRA: Impact of Risk Scoring And Attribution October 2017 Linda Gates-Striby Lggates@ascension.org Disclosures Linda Gates-Striby Nothing To Disclose Increasing Our Focus
More informationPOLICIES AND PROCEDURE MANUAL
POLICIES AND PROCEDURE MANUAL Policy: MP209 Section: Medical Benefit Policy Subject: Medical Error Never Events, Hospital Acquired Conditions, and Hospital Readmission Review I. Policy: Medical Error Never
More information1. Recommended Nurse Sensitive Outcome: Adult inpatients who reported how often their pain was controlled.
Testimony of Judith Shindul-Rothschild, Ph.D., RNPC Associate Professor William F. Connell School of Nursing, Boston College ICU Nurse Staffing Regulations October 29, 2014 Good morning members of the
More informationSubject: Hospital-Acquired Conditions (Page 1 of 5)
Subject: Hospital-Acquired Conditions (Page 1 of 5) Objective: I. To facilitate safe patient care for all Health Share/Tuality Health Alliance (THA) members. II. To encourage and support provider efforts
More informationImproving quality of care during inpatient hospital stays
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Room 352-G 200 Independence Avenue, SW Washington, DC 20201 Office of Communications FACT SHEET FOR IMMEDIATE RELEASE Contact:
More informationImplementing an Outpatient CDI Program L EONTA (L EE) WIL L IAMS, R HIT, CPCO, CPC, CCS, CCD S
Implementing an Outpatient CDI Program PR ES ENTED BY: L EONTA (L EE) WIL L IAMS, R HIT, CPCO, CPC, CCS, CCD S Disclaimer This information is meant to be simply a guide for implementation based on the
More informationRisk Factor Analysis for Postoperative Unplanned Intubation and Ventilator Dependence
Risk Factor Analysis for Postoperative Unplanned Intubation and Ventilator Dependence Adam P. Johnson MD, MPH, Anisha Kshetrapal MD, Harold Hsu MD, Randi Altmark RN, BSN, Herbert E Cohn MD, FACS, Scott
More informationImpacting Quality Initiatives through Documentation Improvement. Fran Jurcak, MSN, RN, CCDS Vice President of Clinical Innovation Iodine Software
Impacting Quality Initiatives through Documentation Improvement Fran Jurcak, MSN, RN, CCDS Vice President of Clinical Innovation Iodine Software Objectives The learner will be able to: Articulate the goals
More informationConnecting the Revenue and Reimbursement Cycles
Connecting the Revenue and Reimbursement Cycles Tuesday, August 19 th, 2014 Toni G. Cesta, Ph.D., RN, FAAN Consultant and Partner Case Management Concepts New York Office And Bev Cunningham, MS, RN Vice
More informationCase-mix Analysis Across Patient Populations and Boundaries: A Refined Classification System
Case-mix Analysis Across Patient Populations and Boundaries: A Refined Classification System Designed Specifically for International Quality and Performance Use A white paper by: Marc Berlinguet, MD, MPH
More informationFY 2014 Inpatient Prospective Payment System Proposed Rule
FY 2014 Inpatient Prospective Payment System Proposed Rule Summary of Provisions Potentially Impacting EPs On April 26, 2013, the Centers for Medicare and Medicaid Services (CMS) released its Fiscal Year
More informationTransitions Through the Care Continuum: Discussions on Barriers to Patient Care, Communications, and Advocacy
Transitions Through the Care Continuum: Discussions on Barriers to Patient Care, Communications, and Advocacy Scott Matthew Bolhack, MD, MBA, CMD, CWS, FACP, FAAP April 29, 2017 Disclosure Slide I have
More informationHospital Inpatient Quality Reporting (IQR) Program
Clinical Episode-Based Payment (CEBP) Measures Questions & Answers Moderator Candace Jackson, RN Project Lead, Hospital IQR Program Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR) Outreach
More informationChapter VII. Health Data Warehouse
Broward County Health Plan Chapter VII Health Data Warehouse CHAPTER VII: THE HEALTH DATA WAREHOUSE Table of Contents INTRODUCTION... 3 ICD-9-CM to ICD-10-CM TRANSITION... 3 PREVENTION QUALITY INDICATORS...
More informationQuality and Health Care Reform: How Do We Proceed?
Quality and Health Care Reform: How Do We Proceed? Susan D. Moffatt-Bruce, MD, PhD Chief Quality and Patient Safety Officer Associate Dean of Clinical Affairs Quality and Patient Safety Associate Professor
More informationReadmissions Moving beyond blame to fill the patient needs. Jackie Conrad RN, MBA, RCC Cynosure Health
Readmissions Moving beyond blame to fill the patient needs Jackie Conrad RN, MBA, RCC Cynosure Health jconrad@cynosurehealth.org 1 51 year old male with 3 acute care admissions and 2 ED visits in the past
More information"Strategies for Enhancing Reimbursement " September 16, 2015
"Strategies for Enhancing Reimbursement- 99080" September 16, 2015 Chat box feature Chat Box is available to you to ask questions or make comments anytime throughout today s webinar. Submit to Host and
More informationSurgical Precision in Clinical Documentation Connects Patient Safety, Quality of Care, and Reimbursement
Surgical Precision in Clinical Documentation Connects Patient Safety, Quality of Care, and Reimbursement by Benjamin J. Kittinger, MD; Anthony Matejicka II, DO; and Raman C. Mahabir, MD Abstract Emphasis
More information2015 Executive Overview
An Independent Licensee of the Blue Cross and Blue Shield Association 2015 Executive Overview Criteria for the Blue Cross and Blue Shield of Alabama Hospital Tiered Network will be updated effective January
More information