Clinical Documentation Improvement

Our physicians, nurses and coding professionals work with your staff to develop an integrated, long-lasting clinical documentation improvement program that is led by your medical staff and supported by your coders and a team of clinical documentation improvement specialists. We customize each training program to meet your needs, so your team receives the help that best fits your facility.

Outcomes include:

• Improved hospital and medical staff profiles
• Increase in Case Mix Index
• Improved coder efficiency
• Improved ICD-9 and DRG accuracy
• Medical records accurately reflecting resources
• Reduced risk of noncompliance
• Reduced physician interactions
• Improved physician understanding of accurate medical documentation
• Reduction in days of unbilled accounts receivable

Accurate clinical documentation affects how your facility is portrayed in hospital and physician profiles. Having an effective clinical documentation improvement program at your hospital can ensure that you receive appropriate credit for complexity of the patient population you treat, enhance your morbidity and mortality statistics and improve severity adjusted length of stay and utilization statistics.

Quality of care is also enhanced with accurate and specific documentation. This leads to better hand-offs between providers, administration of core measures, fewer errors in medical treatment and reduction of risk in legal matters. A medical record with complete documentation leaves no room for error.

We can help your facility understand documentation so you get it right. DCBA's physician-directed programs lead to improved understanding of clinical aspects of diagnoses and procedures, as well as better understanding of coding. We work with your quality committees, Core Measures initiatives and hospital safety programs to enhance communication and improve integration with the coding elements that affect all of these.

DCBA's clinical documentation improvement program is a physician-to-physician program that educates your medical staff and mid-level providers on elements of documentation that provide completeness and value to the medical record. We also work with your team's coders on the clinical aspects of the diseases and procedures to which they assign ICD-9-CM codes.

Our physician consultant meets with your medical staff, specialty by specialty, to discuss cases and provide education on appropriate medical record documentation and how it affects the physician in his particular practice environment.

This is accomplished through many different venues including:

• Holding specialty specific seminars for which the medical staff and their midlevel providers can receive CME or CEU credits.
• Attending individual physician department or educational conferences.
• Making rounds with your Documentation Improvement Team and discussing active cases with the physicians on the floor.
• Providing other informal opportunities for interaction with physicians – due to the many demands of the medical staff, we make ourselves available at any time during our visits. These include potential for early morning or evening presentations.
• We also incorporate into our methodology a member of your medical staff to become physician liaison, a respected champion of the program, when appropriate. This person will be able to provide ongoing instruction to the medical staff after we have left as well as support to the CDI specialists in dealing with medical staff issues.
• We teach the clinical documentation improvement (CDI) specialists as well as the physician liaison our methodology and knowledge base, and provide them with our presentations to assist them in communicating with the medical staff in the future. This enhances the efficacy of the training by providing stability to the program regarding good documentation techniques for your hospital and medical staff.

DCBA provides hands-on training to your documentation team on the review of concurrent and retrospective medical records. This allows team members to evaluate the need for documentation enhancement for specificity of coding and increased coding accuracy long after the training is complete.

During our weekly visits we:

• Provide educational presentations to medical staff and midlevel providers as well as incorporating other professionals into the program (nutritionists, therapists, nurses, etc.)
• Provide one-hour seminars to the documentation team and coders on the clinical aspects of the medical record for which they can receive CEU credits.
• Round with the documentation team, teaching them how to review the medical record in a concurrent process.
• Provide methodologies for communication to the physicians regarding documentation needs for the medical record.

What you get:

• A 350+ page Documentation Improvement Manual
• A resource for the coders and documentation team members through telephone or internet communications with their consultant team
• Templates for documentation clarification questions
• Laminated cards for the medical staff members that provide them with tips and codes specific to their own professional practices
• Methodology for tracking the effects and effectiveness of the program and the physicians' participation in the clinical documentation improvement initiative

Training Note:

Our experience has shown that a physician-led program produces a collegial environment between the project members (liaison physician, documentation specialists and coders) and the medical staff, with enthusiasm generated toward their getting recognition for their accomplishments. The team's ability to act independently during and after the program uniformly leads to long-lasting positive results.