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Clinical Documentation
Improvement
Jhonatan Munoz MD
Quality
Severity of Illness (SOI)
Risk of mortality
Clinical outcomes
Your clinical documentation impact
www.AllenShariff.com
Clinical Documentation Improvement
Team Effort
A collaborative effort to achieve high quality documentation able to reflect
severity and mortality risk of our patients..
www.AllenShariff.com
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
www.AllenShariff.com
• 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
www.AllenShariff.com
• 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
www.AllenShariff.com
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
www.AllenShariff.com
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
You are an essential part of this documentation
improvement effort

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CDI introduction

  • 2. Quality Severity of Illness (SOI) Risk of mortality Clinical outcomes Your clinical documentation impact
  • 3. www.AllenShariff.com Clinical Documentation Improvement Team Effort A collaborative effort to achieve high quality documentation able to reflect severity and mortality risk of our patients..
  • 4. www.AllenShariff.com 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
  • 5. www.AllenShariff.com • 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
  • 6. www.AllenShariff.com • 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
  • 7. www.AllenShariff.com 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
  • 8. www.AllenShariff.com 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