The Louisiana Health Information Management Association (LHIMA) is pleased to sponsor and offer a highly informative webinar titled Evaluation and Management-The Standard of Physician Documentation, presented by Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, CCDS, C-CDI, C-DAM and Jacob Martin, MD, C-CDI, CDI-PA.
Most hospitals and health systems have invested in Clinical Documentation Improvement Programs in the inpatient setting, now migrating to the outpatient arena. Most recently the professional associations representing the CDI profession have elected to change the name from Clinical Documentation Improvement to Clinical Documentation Integrity. With the name change to Clinical Documentation Integrity, current CDI processes must adapt to actually make headway in achieving real measurable meaningful sustainable integrity in physician documentation that supports both quality of care as well as hospital optimal net patient revenue with preservation. The word “Integrity” in CDI requires CDI to recognize the medical record as a Communication Tool versus a Reimbursement Tool. This ability to treat and conduct the record as a communication tool requires a distinctly different CDI skill set, knowledgebase, and core competencies rooted in understanding, defining and applying best practice standards and principles of physician documentation that effectively communicates patient care. These best practice standards and doctrines of documentation incorporate principles of the Evaluation and Management that serve as the basis for the physician’s reimbursement.
CDI professionals who wish to advance their knowledge and skill sets in defining documentation integrity, working with physicians as true colleagues and partners in achieving clinical documentation excellence, helping physicians work smarter not harder by becoming proficient in effective methodologies of charting in the record by applying principles of E & M documentation, will want to make it a point to register for this webinar.
Objectives of the presentation include:
- Understand and appreciate E & M concepts and direct natural relationship to quality and completeness of clinical documentation
- Learn a practical approach to chart review that incorporates principles of E & M assignment and engages the physician in true documentation improvement initiatives
- Understand and practically apply the 3 key components of E & M assignment into promoting and achieving best practice standards of documentation, optimizing CDI initiatives for all the right reasons beyond case mix and reimbursement key performance indicators
- Integrate principles and concepts of E & M into documentation improvement efforts that capture and reflect clinical judgment, thought processes, medical decision making and proper establishment of medical necessity
December 8, 2020
1.5 – Information Protection: Access, Disclosure, Archival, Privacy and Security
Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, CCDS, C-CDI, C-DAM
Glenn Krauss is well-recognized and respected subject matter expert in the revenue cycle with a specialized emphasis and focus upon collaborating and working closely with physicians in promoting, advocating for, educating and achieving sustainable improvement in clinical documentation that accurately reflects and reports the communication of fully informed coordinated patient care. His experiences include working with a wide variety of healthcare systems spanning the entire spectrum ranging from critical access hospitals, community hospitals, Federal Qualified Healthcare Centers to large academic medical centers and fully integrated healthcare systems. He possesses twenty-five plus years of progressive practical hands on experience in clinical coding and documentation improvement, subscribing to the philosophy that quality of medical record documentation strongly correlates with overall quality of care achieved and the overall achievement of a high performing revenue cycle. Glenn has demonstrated the unique skill sets and core knowledge of principles and standards in best practices of clinical documentation, effectively and successfully driving physician engagement through proven strategies that create and foster a sustainable model for clinical documentation improvement. What sets Glenn apart in the clinical documentation improvement arena is the recognition of clinical documentation effectiveness, accuracy, completeness, and contextual consistency as fundamentally integral and intertwined with all components of the revenue cycle. He has conducted encompassing assessments of CDI programs utilizing a unique approach that embraces the concept of holistic documentation improvement that incorporates elements of complete, accurate and consistent documentation in support of quality patient care, medical necessity and optimal coding and reimbursement with financial and compliance integrity. Glenn is a professional speaker, sought after for speaking engagements throughout the country on a wide variety of cutting edge thought provocative clinical documentation improvement topics and subjects. Glenn has served on the ACDIS Advisory Board as well as founded the WI ACDIS Chapter, leading a highly active chapter for six years. The inspiration for creation of a LinkedIn page titled Physician Documentation Improvement- A New Paradigm is the goal of creating a forum for sharing thought provocative ideas and concepts on all things CDI including an awareness of the opportunity to transform the profession of CDI to one that truly supports the patient and the overall healthcare delivery model.
Jacob Martin, MD, C-CDI, CDI-PA