Challenges of Clinical Documentation

March 5, 2019

Performance Transformation

Almost all reimbursements in the healthcare industry are dependent on documentation of clinical and quality activities in the medical record. Therefore, each healthcare provider, hospital, and provider group should be well versed in how to document the following accurately:

Evaluation and Management (E&M) Services
Procedures and Non-E&M Services (CPT)
Diagnoses (ICD10)
Diagnostic Related Groups (DRGs)
Hierarchical Clinical Conditions (HCCs)
Quality of Care Measures (CMS – MSSP, MIPS, APMs, JC Standards)
Present on Admission (POA)

Assuring this happens requires a robust clinical documentation improvement (CDI) program, and Coker Group can help you build such a program that includes the following key elements:

Baseline education and updates for all providers
Routine audits of clinical documentation activities (inpatient and outpatient)
Adoption of IT systems that can support this complex task
Hiring and training of clinical documentation support staff that can work hand-in-hand with your providers to assure your CDI program functions smoothly and effectively
Selection of CDI outcome measures that allow you to monitor the CDI program’s effectiveness and efficiency over time
Responding to audits that will inevitably occur with even the best organizations

Contact us today for more information on the above clinical documentation services and to speak with Rosalind Cordini, Senior Vice President.

Social Share

Contributors

Roz Cordini, JD, MSN, RN, CHC, CHPC

Senior Vice President, Regulatory Compliance & Audit Services

Share this post

Related Insights

View All Insights

5 Fatal IT Vendor Contract Mistakes

Prevent devastating consequences that can adversely impact the company.

Making the Most of Your MACRA Reporting

Never Lose a Step while Filling a C-Suite Vacancy

When and How to Convert to Another EHR System

Is your EHR at the end of its useful life?

Coker Interviews AHLA President Rob Niccolini

Incorporating Value-Based Metrics into a Physician Compensation Plan

Myth of the Median

EHR Ease of Use - Does it Exist and How do we Define it?

Identifying and Retaining Leadership Talent

Collections Guarantee or Stipend? That is the Question!

What's the best way to staff your ER?

Anesthesia Subsidy Strategy: Ensure a Strong Support Structure is in Place

85-95% of all hospitals directly or indirectly subsidize their anesthesia services.

Understanding Value-Based Compensation Models

How should physician compensation models evolve with the shift toward value?

Implementing Sustainable Telehealth Strategy and Operations with PREMEDEX

Do M&A Deals Really Result in Long-Term Value Creation? Increasing Your Odds of Success

The Year in Review

2018 Updates to Macra

Harmony-MD

Moving Forward With MACRA: A Review of Progress, Changes, and Preparation

Direct to Employer Contracting Arrangements: A Response to Rising Premiums and Compromised Care

CDI – It’s No Longer Just About Inpatient Services

The Increasing Demands on Internal Recruitment Departments

Missing Links of Revenue Cycle Management

Is Your EHR Company Holding Your Patient Data Hostage?

EHR companies may charge an excessive fee to retrieve your patients’ data.

Invest in Developing Your Physician Practice Leaders While Helping Them Achieve Organizational Objectives

Coker’s Physician Practice Leadership Development Program

Building a High-Performing Physician Enterprise

Deliver more value in healthcare as a high-performing physician enterprise.

Chief Information Officers: Exceptional Leaders Address their Sub-Cultures

Will Innovation Capture Value-Based Market Share?

Primary care value-based care model disrupts the market.

Healthcare Mergers and Acquisitions: How to Maximize Success

Innovative Alignment Options for Rural Hospitals

The Dangers of an Unstable IT Infrastructure

Coker IT Assessment: What's Involved?

Developing Management Services Organizations for Private Practices: The Newest Version of Strength in Numbers?

Stay competitive in a rapidly consolidating market by leveraging the growing prominence of MSOs in recent years.

Sourcing Candidates: How to Identify Qualified Leaders

So Your Healthcare Organization Survived COVID, What Comes Next?

Perform an operational and strategic review.

Has Your Practice Had an Annual Exam? Check These ‘Vital Signs’ to Assess the Health of Your Operations

Physician Compensation Advice: Are Your Compensation Arrangements Fair Market Value and Commercially Reasonable?

wRVUS: Are yours accurate?

Reassessing Value in Hospital-Based Subsidy Arrangements

Evaluate and document the value of your service provider.

Compensation Best Practices for Physician Enterprises

Employee Incentive Programs in an Era of Change

Lawmakers Grapple with Artificial Intelligence Regulation as Popularity and Utilization Grow

ChatGPT could improve providers' productivity

Coker Elevates Talent with 2024 Team Member Promotions

Promotions are effective April 1, 2024.

Survey Says… How 2020 Will Impact Market Survey Data

When new survey data becomes available, don’t just go with “survey says!”

Developing Competent Physician Leaders: Maximizing Talent to Boost Operating Results

EHR Documentation Integrity Risks: Ten Ways to Stay Compliant

Managing Health System Access Points in the Wake of COVID-19

External Value-Based Incentives - What Should You Do With Them?

Beyond Borders: Telemedicine’s Vital Role in Healthcare Transformation

Telemedicine bridges the gap in access to healthcare for rural communities.

Charting a Roadmap to Financial Sustainability in an Increasingly Subsidized World

Trinity Hunt Partners Establishes Healthcare Advisory Platform with Investment in Coker

Trinity Hunt will work closely with Coker’s skilled team to facilitate expansion.

Strategic Planning Video Series: Understand the Starting Point

Embracing Employment: How to Drive Mutual Gain, Not Mutual Destruction

A Bad Case of the HCC-Ups—The High Cost of Using Improper Diagnoses Codes

Strategic Planning for Healthcare Systems and Practices

Prepare Your Organization for Unexpected Leadership Gaps

Just When You Think You’ve Heard It All: CMS’s Proposal for an E/M Makeover

Does Your HIT Vendor Contract Leave Your Organization Exposed and at Risk?

The ICD-10 Freeze is Over: 2017 ICD-10-CM/PCS Coding updates and the Impact on Clinical Documentation Improvement

Clearing the Air on Professional Services Agreements (PSAs)

The best alternative to hospital employment.

Challenges of Clinical Documentation

Benchmarking to Perfection

Physician Practice Mergers: Leveraging Strength in Numbers

Maximizing Reimbursement in the Telemedicine Environment

MACRA and MIPS in Physician Practice Valuations

Announcing the Acquisition of Healthcare Consulting Firm, TTG Healthcare Advisors

Webinar - Bundled Payments: What All Providers Should Know About This Emerging Payment Model

Physician Documentation: My, How Times Have Changed!

CMS Issues 2023 Physician Fee Schedule Final Rule

The conversion factor will decrease by 4.5%.

Our Remote Workforce is Here for You

Developing a Physician Leadership Strategy

Pursuing Patient Access: Explore Strategies to Maximize Value for Patients, Providers, and Health Systems

Strategic Questions Boards are Asking about IT

How to Use Strategic Workforce Planning to Succeed

Key Factors for Developing High-Potential Employees

AAPCP Launches New CPCV Credential to Set Standards in Provider Compensation Valuation

CPCV Credential Empowers Healthcare Organizations with Data-Driven Compensation Strategy through Certified Experts

Key Elements of a Cyber Liability Insurance Policy for Healthcare Providers

8 areas to cover when considering cyber liability insurance.

Practice Management: An Integrated Approach to Short- and Long-term Improvement

Three Critical Keys Before Opening a Physician Recruitment Search

12 Mistakes Executives Make on Resumes (and How to Avoid Them)

Avoid making common resume mistakes that put your resume into the “no” pile.

Strategic Planning Video Series: Ensure You Have the Right Resources

The final installment of the 5-part video series on strategic planning.

How the CY 2022 PFS Final Rule Affects Split/Shared Visits and Critical Care Services

On May 3, 2021, CMS withdrew provisions for split/shared E/M visits and critical care services from the Medicare Claims Processing Manual IOM

MACRA—What IS it?

Use a Checklist to Track Documentation of Community Need

“CIO-on-Demand” – An Innovative Approach to Meet Interim CIO Needs

What Are Your Margins? Owing to MACRA/MIPS, They Soon May Change

Are Single-Specialty CINs as Valuable as Multispecialty CINs?

Why Every Healthcare Organization Needs a CIO

The Growing Issue of Compensation Governance

IT Choice Points

Enhance Your Executive Compensation Model to Improve Retention and Recruitment

PSA Progression: What’s Next in the Evolution of Professional Services Agreements?

CMS Announces New Options for MACRA Participation

Open Call for Healthcare Leaders: Coker’s 2024 Advanced Practice Provider Strategy & Oversight Survey Now Open

Survey to Establish Benchmarks for Advanced Practice Providers; Participants Needed by the end of July

Health System Practice Investment: What’s the Cost?

Hospitals’ multi-specialty physician groups invested almost $196,000 per employed physician.

Could I Benefit from an Appraisal Review?

Avoiding Four Common Pitfalls in Revenue Cycle Management

Medicare Access and Chip Reauthorization Act: What You Need to Know About MACRA

Solidifying Organizational Development: Identifying and Retaining Leadership for Your Organizational Culture

Going Beyond EHR: Leveraging AI and Digital Transformation Strategies

Unlocking the Future of Healthcare: How AI and Digital Transformation Enhance EHR Capabilities