This document discusses clinical documentation improvement and its importance for quality of care, assessing severity of illness and risk of mortality, supporting length of stay and services provided, and impacting reimbursement. It emphasizes that clinical documentation is a team effort between doctors and coders to use precise language that reflects a patient's condition and supports medical necessity. The future of clinical documentation improvement includes enhancing safety, substantiating necessity, and properly capturing severity of illness.

1. Clinical Documentation
Improvement
Jhonatan Munoz MD

2. Quality
Severity of Illness (SOI)
Risk of mortality
Clinical outcomes
Your clinical documentation impact

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Clinical Documentation Improvement
Team Effort
A collaborative effort to achieve high quality documentation able to reflect
severity and mortality risk of our patients..

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What is Clinical Documentation Improvement?
• Quality vs quantity
• Doctors language and coder language
• Working collaboratively with coders to use the right verbiage.
• Is my note able to tell you what needs to be done tomorrow?
• Is this patient one more day in the hospital medically necessary.
• Clinical record that supports the LOS and services provided.
• Copy paste notes, is it fraud?
• Can information be taken from lab results, consultants notes?
• Conflicting information
The future of Clinical Documentation

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• Patient safety through enhanced provider-to-provider
communication
• Substantiation of medical necessity
• Individuals right under HIPAA to Access their Health
Information
• Proper capture of severity of illness, morbidity mortality risk

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• DRGs are based on several components
• Principal diagnosis
• Medical vs. Surgical patient
• Comorbidities & Complications (CCs) & Major CCs (MCCs)
• Age, Discharge status
MS-DRGs
Diagnostic Related Group
(DRG)
Complications ComorbiditiesDRG

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MS-DRG Triplet Example
DRG MDC TYPE MS-DRG TITLE WEIGHT GLOS ALOS
637 10 MED DIABETES W MCC 1.3888 4.2 5.5
638 10 MED DIABETES W CC 0.8252 3.0 3.7
639 10 MED DIABETES W/O CC/MCC 0.5708 2.2 2.6
• Complications on low DRG’s groups
• Payments
• Hospital specific rates range from approximately $5,000 to $8,000
 Diabetes with MCC = $7,035
 Diabetes w/o CC/MCC = $2,779
 Variance - $4,256
• What kind of patients is my hospital treating, complications
MS-DRG Table 5 Final Rule FY2013

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Physician Query Process
- When there is conflicting, imprecise, incomplete,
illegible, ambiguous, or inconsistent documentation
- Identification of clinical indicators not linked to a
diagnosis
- Clarification of a problem being present on admission
or hospital acquired

9. You are an essential part of this documentation
improvement effort