Tag: Clinical Documentation Improvement

When Pursuing CDI, Using Risk Adjustment Is Vital

As healthcare has moved away from fee-for-service reimbursement models toward a more value-based system, the idea of using risk adjustment to account for individual patient risk and chronic conditions has become far more important for providers seeking to maximize quality of care.

In today’s healthcare environment, providers are often required to fight simultaneous battles on several fronts. For those pursuing clinical documentation improvement (CDI), they must balance sometimes-conflicting regulatory demands, workflow needs, etc. Further exacerbating the problem is the persistent shift of care provision to the ambulatory setting and the increasing demands it places on provider organizations.

As we have discussed in previous blog posts, outpatient CDI efforts face a number of unique challenges, such as decidedly larger case volumes than most inpatient settings and far shorter clinical visits. These shorter visits produce less usable patient data and offer a condensed window during which multiple team members must work in synchrony—accurately and efficiently—to gather that data. Outpatient providers must also go further, factoring in risk adjustment for each individual in their larger patient populations as well.

Often, problems with risk adjustment appear when inaccurate or incomplete diagnosis coding slips through the documentation workflow. For instance, failure to capture patients’ Hierarchical Condition Categories (HCCs)—and recapture year-over-year—can greatly skew risk scores for individual patients and potentially the overall population. Such mistakes can filter downstream to errors in patient care and increasing claim denials and, potentially, wreak havoc on pay-for-performance reimbursements.

This dynamic puts increased pressure on physicians to capture correct documentation at the point of care—getting it right the first time without a great deal of revision. Many have addressed the issue through Computer Assisted Physician Documentation (CAPD), which provides a number of CDI features. CAPD improves accuracy and lessens physicians’ burdensome workflow by precluding the need to rehash previously captured documentation.

The goal of these products is to allow physicians to complete patient care documentation faster and spend more time with their patients. Unfortunately, many traditional products, which were designed for inpatient settings, lack effective integration of risk adjustment. As a result, many providers are prevented from seeing the most accurate picture of the population they serve—and value-based care programs are not as successful as they could be.

To learn about PowerSpeak+RAPID—a CAPD platform combining powerful front-end medical speech recognition software (PowerSpeak) and Risk Adjusted Physician Documentation (RAPID)—contact Saincesaince inc logo

Saince expands its Clinical Documentation Improvement (CDI) services to US customers from their global offices

Saince CDI Services Image

At a time when hospital reimbursements are not only under tremendous pressure but are also changing from fee-for-services model to value based models, maintaining the quality and integrity of clinical documentation has become paramount.

To ensure that their clinical documentation processes are meeting the expected quality and integrity standards, hospitals have to review their patients’ charts in their clinical documentation improvement (CDI) departments. Currently there is a severe shortage of trained and experienced CDI specialists in the country resulting in hospitals and other care settings not being able to review all the patients’ charts. Such skills shortage is also not only making it expensive for hospitals to review the all the charts but is also limiting their ability to expand the activity into other care settings such as outpatient and emergency room operations. This inability to review 100% of the patient charts in their CDI departments is resulting in under reimbursements for the level of care they have provided to patients, and is also severely impacting their hospital’s quality scores.

In order to address this acute shortage of CDI specialists, Saince, which has been providing transcription and clinical documentation improvement services for hospitals across the country for well over a decade, has taken a leadership role and has become the first company in the industry to also provide CDI services from its offices located in India. In an effort that took more than a year, Saince has identified and hired exceptionally talented physicians with years of clinical experience behind them in their India office. Saince has invested heavily in training these physicians in medical coding and clinical documentation improvement. Thanks to AHIMA, which resumed offering its Certified Coding Specialist (CCS) examination in India, all these physicians are now CCS certified. With exceptional skills and experience, these teams are now ready to provide CDI services to all types of healthcare settings – inpatient, outpatient, ER etc. Saince’s India offices are certified by International Standards Organization (ISO) for quality processes (ISO 9001) and data security (ISO 27001).

Now hospitals across the US have access to top level talent to meet their need for clinical documentation improvement services.