From intimidating to integrity: Enhancing clinical documentation has been saved
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From intimidating to integrity: Enhancing clinical documentation
A data-driven, people-centered approach to clinical documentation integrity (CDI)
Is your health system documentation process capturing the right insights—or missing out on the complexities of patient care? Our offerings can help you confirm that provider documentation is in alignment with relevant guidance¹ and implement improvements to how you classify health services. See how our CDI services can analyze your documentation strategies for potential opportunity.
Are there CDI opportunities your organization is leaving on the table?
Proper CDI is crucial in helping health care systems effectively track patient care and categorize delivered services to their respective diagnosis, procedures, and diagnosis related group (DRG) codes. Effective coding—classifying health services by standardized “codes”—helps organizations identify the care they provide more precisely, which can enable accuracy in billing statements, reimbursements, and reporting. Yet, many organizations find themselves attempting to remedy the challenges of poor, unspecific clinical documentation.
Regulatory risk, reduced quality of patient care, and financial losses can be the side effects of incomplete or unspecific clinical documentation to support all patients diagnoses which can produce data gaps within health care systems.
Enhanced CDI—from diagnosis to treatment
Our end-to-end approach to CDI programs is designed to help identify, address, and alleviate prevalent challenges in documenting health services to the highest level of specificity and comprehensiveness. We collaborate directly with your workforce—including clinical documentation specialists, physician executives, and electronic health record (EHR) certified leaders—to build a center of excellence CDI program. This helps to establish alignment on organizational objectives to leverage technology (e.g., EHRs and CDI modules) to drive and optimize your workflow processes. Furthermore, our CDI and coding insights can help drill down into your documentation approaches.
Check up on your CDI with Deloitte
Let Deloitte help you elevate your end-to-end clinical documentation program to create a more accurate supporting trail of patients that you are treating. Our team of CDI professionals come with a wealth of experience in examining clinical documentation.
Our differentiated CDI strategy is centered on key goals to help track growth opportunities for your health care organization.
Data-driven analytics
We utilize our proprietary analytics tools to identify key areas of opportunity for CDI functions, which helps drive our assessment of people, process, and technology. Also, the results help inform the patient chart selection when kicking off the root cause analysis and pre-bill review process.
Prioritizing people
The evaluation of people supporting CDI, coding, and clinical spaces helps drive our understanding of where bottlenecks, inefficiencies, and areas for potential improvement exist. We also initiate conversations with chief financial officers and physician executives to obtain leadership buy-in and insights to drive strategic approaches.
Process forward
We assess CDI, coding, and quality assurance practices, and compare them to leading processes. The final deliverables can include, but are not limited to, staffing models, enhanced process manuals, updated policies and procedures, and revamped metrics and goals. These can help organizations in maintaining an effective end-to-end CDI program and enhancing provider engagement.
Technology enhanced
Our approach can focus on incorporating tech-powered solutions to help your organization maintain a sustainable and highly effective end-to-end CDI program, inclusive of coding and quality assurance needs.
Our services
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Leverage our inpatient (IP) CDI and coding analytics to monitor key metrics:
- Major complication or comorbidity capture rates
- Alternative diagnosis
- Provider responsiveness and agreement rate
- Risk of mortality and severity of illness
- Diagnosis and procedure coding
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Utilize our industry-leading outpatient (OP) tools to evaluate the following against leading practices:
- Diagnosis
- Risk adjustment factor scores
- Observation patients
- Evaluation and management distribution
- Procedure capture
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The Challenge:
Intimately understanding customer needs, wants, and pain points is key to the center office concept. To provide meaningful customer experiences, enterprise service delivery heads are pursuing strategies built around collaboration, accessibility, and integration. Each of these strategies, in turn, is continually reinforced through leadership actions, workforce programs, and employee communications.
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Delivered value
Our CDI services can help the health care industry streamline clinical documentation methods and introduce new opportunities for potential growth, as evidenced by the outcomes we’ve helped to deliver for the 450+ health care organizations we have served over the past 30 years.
Are you ready to accelerate and refine your clinical documentation? Connect with our CDI professionals to learn how to help enable greater clinical documentation accuracy throughout your health care organization.
Get in touch
Donna Guray-jurk | Suzanne Whitworth | Heather Hagan | Angie Diaz |
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Endnote
¹ Relevant guidance such as ICD-10-CM Official Coding Guidelines and American Hospital Association (AHA) Coding Clinics, Centers for Medicare and Medicaid Services (CMS), and Association of Clinical Documentation Integrity Specialists (ACDIS)/American Health Information Management Association (AHIMA) Query Practice Brief, and the AHIMA Standards of Ethical Coding)
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