Embracing and Integrating Clinical Data Integrity

EDITOR’S NOTE: The following is an outline of a presentation by author Bonnie S. Cassidy scheduled to take place at the American Health Information Management Association (AHIMA) “Advancing the Documentation Journey” Summit, which began Monday, July 31 and continues today, Tuesday, August 1 in Washington, D.C.

During my presentation yesterday at the American Health Information Management Association (AHIMA) “Advancing the Documentation Journey” Summit this week, the focus will be on clinical documentation improvement (CDI), clinical indicators, and using evidence-based medicine – along with the notion that all knowledge and data must be shared. The “collaboration” in the title speaks to how all must work together in today’s hospital environment to help get stays paid.

Core clinical documentation integrity has never been more vital since performance-based payments are now directly linked to quality measures that require data and information. Health information governance, quality monitoring, performance indicators, risk of mortality, severity of illness, evidence-based medicine, coding, and CDI programs provide significant benefit as it pertains to these new payment models since they allow a deep dive into information collection processes, sources, and uses. Effective care leads to the best patient outcomes, avoiding underuse or overuse of medical resources. Evidence-based care guidelines help providers and health plans drive effective care in their own work and through collaborative efforts in your organization.

Presentation Outline

1. Introduction to the meaning of core clinical documentation integrity
   1. Addressing needs across the care continuum
2. Embracing a culture of collaboration: CDI, clinical indicators, and evidence-based medicine knowledge and data must all be shared  
3. III. Answer the questions of who, what, when, where, and why re: core clinical documentation integrity
4. Summarize

Presentation Content

Everything old is new again! Utilization review should be a key component of care coordination programs working in tandem with CDI. One example is that point-of-entry utilization review staff members play a very important role in reviewing and discussing admission decisions with providers. This includes ensuring that there is a clear order for the type of admission (inpatient, outpatient, observation); that documentation clearly supports the admission decision; and orders for treatment support both the type of admission and medical necessity. Review at the point of entry is even more critical than in the past being as the Merit-Based Incentive Payment System (MIPS) will take effect on Jan. 1, 2019, consolidating existing quality and utilization-based programs, including the Physician Quality Reporting System (PQRS), the Value-Based Modifier Program (VBMP), and the “meaningful use” Electronic Health Record (EHR) Incentive Program Certified EHR Technology (CEHRT).

Audience Benefits

This presentation will prepare you to evaluate critical success factors to bring you and your organization to the next level of preparedness for linking clinical documentation integrity to reimbursement.

The presentation is intended for an audience of advanced-level experience for health information management (HIM), CDI, utilization review (UR), coding, case managers, and billing specialists.