Learn best practices for Clinical Documentation Integrity, identify documentation gaps, and enhance physician communication skills.
Clinical Documentation Integrity programs, formally known as Clinical Documentation Improvement programs have existed since 2008 with the advent of the MS-DRG coding and billing system. The need for complete and accurate documentation has evolved to today where payers are expecting to see an accurate and complete account of patient care, incorporating the telling and describing of the patient story and the establishment of medical necessity.
CDI processes have not evolved to meet the changing needs and requirements of physician documentation. By attending this course, attendees will learn how to define best practice standards and principles of documentation, be able to identify true insufficiencies in documentation and even more importantly how to address with the physician. Attendees will become familiar with the critical nature of the physician’s clinical reasoning and clinical judgement, be able to incorporate these elements into the chart review process, recognize documentation insufficiencies that detract from a complete assessment and plan, and converse with physicians to address and prevent clinical validation denials. Attendees will be able to review a record efficiently in 5 minutes and hone in areas of documentation to address, helping physicians achieve true physician documentation excellence with proactive preemptive denial avoidance documentation.
Learning Objectives
- You will be able to define standards and best practices of physician documentation.
- You will be able to describe common documentation insufficiencies that contribute to medical necessity and clinical validation denials as well as level of care and DRG downgrades.
- You will be able to discuss with the physician how to strengthen the documentation and meet the best practice standards of documentation efficiently and effectively.
- You will be able to identify documentation insufficiencies contributing to denials using real case studies and learn how to address and communicate with physicians.
Agenda
Speakers
Glenn Krauss, B.B.A., RHIA, CCS, CCS-P, CPUR, CCDS,
op Gun Audit School- CEP & founder of Core-CDI, co-founder of Top Gun Audit School; Core-CDI.com and TopGunAuditSchool.com
- Creator and host of a monthly podcast titled Wiser Wednesdays- Experience Speaks
- Previously held position as director of clinical documentation improvement at a large Level I Trauma Academic Medical Center in the Southwest
- Practice emphasizes all aspects of reimbursement and revenue cycle processes, including ICD-10 and CPT/evaluation and management coding, clinical documentation improvement, denials management/denial avoidance and physician practice management
- Conducts regular seminars and workshops on numerous areas, including medical necessity establishment from a physician perspective, clinical documentation improvement, denials management, and coding education and training
- Author of several publications related to clinical coding, establishment of medical necessity beyond medicare local coverage determinations, soliciting buy-in from physicians in the rollout of clinical documentation improvement programs, and the role of the clinical documentation improvement specialists beyond improving MS-DRG assignment and resulting financial reimbursement including how CDI can best transform and contribute to a denials avoidance approach to documentation excellence
- Created and managed an active LinkedIn forum titled Physician Documentation Improvement-A New Paradigm intended to provoke thought provocative discussion on anything CDI related
- Certificate in Health Information Management, University of Washington in Seattle
- Member of AHIMA, American College of Physician Advisors, Health Care Financial Management Association, Association for Clinical Documentation Improvement Specialists
- B.B.A. degree in management, Hofstra University in Hempstead, New York
- Can be contacted at 603-303-3337 or Glenn.Krauss@Core-CDI.com
Who Should Attend
This live webinar is designed for medical records directors, health information directors, coders, billing managers, business managers, office managers, nurses, hospital administrators, social workers, counselors, release of records professionals, and compliance managers.
