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

Rural Healthcare: Strategic Solutions for Sustainability and Growth

Explore solutions that help rural healthcare providers thrive despite unique challenges and limited resources.

Avoiding Four Common Pitfalls in Revenue Cycle Management

Lawmakers Grapple with Artificial Intelligence Regulation as Popularity and Utilization Grow

ChatGPT could improve providers' productivity

E/M and ME: How will the 2021 E/M coding changes impact medical practices?

The Growing Issue of Compensation Governance

A Lookback at the 2021 Top Five Trends in Healthcare

What did we get right?

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

Coker Interviews AHLA President Rob Niccolini

Understanding Call Pay Compensation Methods

Structure call coverage arrangements to comply with regulations.

Telehealth Post-PHE: How to Prepare for Reduced Reimbursement and Increased Regulatory Scrutiny

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

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

Executive Search Services: What are the Benefits?

Collections Guarantee or Stipend? That is the Question!

What's the best way to staff your ER?

Creating Balance Between Clinician Needs and Cybersecurity Policies

Vendor Selection and Negotiating EHR Vendor Contracts

IT Assessments: An Essential Initiative

Could I Benefit from an Appraisal Review?

Identifying and Retaining Leadership Talent

Innovative Alignment Options for Rural Hospitals

It’s Always a Good Time to Clean Up Your Vendor Contracts

Contracts can renew automatically without permission or approval.

Key Factors for Developing High-Potential Employees

Interim Management Solutions: Take Time to Pursue the Right Hire

Strategic Challenges and Associated Risks of Greater APP Utilization

wRVUS: Are yours accurate?

Chief Information Officers: Exceptional Leaders Address their Sub-Cultures

Top Trends in Healthcare for 2023

What's on the horizon for 2023?

Five Hot Topics to Consider While Strategic Planning

Interim “C” Suite Management: Develop a Customized Job Description

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

Making the Most of Your MACRA Reporting

Find, Develop, and Retain Successful Executive Leaders—a Three-pronged Approach!

Use a Checklist to Track Documentation of Community Need

Physician Practice Mergers: Leveraging Strength in Numbers

Myth of the Median

Health System Practice Investment: What’s the Cost?

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

Harmony-MD

Key Elements of a Cyber Liability Insurance Policy for Healthcare Providers

8 areas to cover when considering cyber liability insurance.

Revenue Cycle Management – Look Out for the Red Flags!

Achieve Quality Improvement through IT Integration

Hospital-Physician Disengagement – Say that Again?

MACRA and MIPS in Physician Practice Valuations

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

Revenue and Quality Integrity: A Comprehensive Approach to Coding, Compliance, and Clinical Documentation

The Dangers of an Unstable IT Infrastructure

Revenue Cycle: Is Your Process Healthy? The Numbers May be Misleading!

Enhance Your Executive Compensation Model to Improve Retention and Recruitment

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

Expanded Guidance from CMS for Telehealth Services Provided at Rural Health Clinics and Federally Qualified Health Centers During the COVID-19 Public Health Emergency

Incorporating Value-Based Metrics into a Physician Compensation Plan

Interim Management: Allow your Organization Time to Find Expert Leadership

Coker IT Assessment: What's Involved?

Physician Compensation Technology Partnership Redefines Value

Survey Says… How 2020 Will Impact Market Survey Data

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

Navigating the Documentation of Community Need

Addressing the Challenges of C-Suite Recruitment

Announcing our New Book on Private Equity and Healthcare

Press Release: Coker Team Authors New Book on Private Equity and Healthcare

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

MACRA Implementation: Have you Established a Plan to Succeed?

Achieving and Maintaining A High Performing Revenue Cycle

Compensation in a Value-Based World—It’s Well Underway

Physicians in Practice: Ways to Align and Remain Independent

Corporate entities now employ 3 out of 4 physicians.

CrowdStrike Outage Impacts US Healthcare: Protecting Healthcare Organizations

Protect Your Healthcare Organization from IT Disruptions: Learn from the CrowdStrike Outage

Healthcare Consulting Firm, Coker, Announces Acquisition of NorthGauge Healthcare Advisors

Patient Access

Coker Elevates Talent with Fall 2024 Team Member Promotions

Promotions are effective October 1, 2024.

IT Choice Points

Compensation Best Practices for Physician Enterprises

When and How to Convert to Another EHR System

Is your EHR at the end of its useful life?

How to Use Strategic Workforce Planning to Succeed

MACRA—What IS it?

Maximizing Reimbursement in the Telemedicine Environment

Strategic Planning Video Series: Ensure You Have the Right Resources

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

The Dangers of an Unstable IT Infrastructure

3 Questions to Ask While Fighting Healthcare Inequities

Intentional strategic planning combats healthcare inequities.

Navigating the Digital Transformation Maze in Healthcare

Insights from the 2024 Becker's IT + Digital Health + RCM Conference

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

Building a High-Performing Physician Enterprise

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

Coker ValuePath™ Services: Successfully Navigate the Path to Value

Beyond Borders: Telemedicine’s Vital Role in Healthcare Transformation

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

EHR Documentation Integrity Risks: Ten Ways to Stay Compliant

Are Single-Specialty CINs as Valuable as Multispecialty CINs?

Four Areas to Incorporate in Your Hospital Service Line Strategic Planning

Implement Healthcare Leadership Development to Maximize Profitability

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

Five Steps to Building a "MACRA Ready" Physician Compensation

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

Strategic Questions Boards are Asking about IT

A Strategic Systematic Approach to Community Health Needs Assessment (CHNA): A Living Plan for Your Community's Health Improvement

2021 Physician Fee Schedule Updated after COVID-19 Stimulus Package Signed

Physician Documentation: My, How Times Have Changed!

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

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

Next Generation MSOs: Strategies to Grow beyond Traditional Practice Management Services

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

Coker’s Physician Practice Leadership Development Program

Revenue Cycle Management - It's More Than You Think

Increase Operational Efficiency Through Scheduling Options

Missing Links of Revenue Cycle Management

Strategic Planning Video Series: Set Mile Markers Along the Road

90% of organizations fail to execute their strategies successfully.

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

Don’t Write-Off Timely Filing Denials

Practice administrator recovered over $60,000 in unpaid claims that would have otherwise been written off.