MSHIMA | Evaluation and Management-The Standard of Physician Documentation

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.

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, knowledge base, 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

Published February 3, 2021

Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, CCDS, C-CDI, C-DAM

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Jacob Martin, MD, C-CDI, CDI-PA

  • MSHIMA Member: $49
  • Non-Member: $69

# of CEs: 1.5 – Data Structure, Content and Information Governance

AHIMA
This educational offering has been approved for continuing education credit for use in fulfilling the continued education requirements of the American Health Information Management Association (AHIMA).

AAPC
CEUs are accepted from programs sponsored by AHIMA national offices and the state or regional AHIMA branches. One hour of instruction is worth one CEU.  A certificate of attendance or completion is necessary to show participation.

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Course Includes

  • 1 Lesson
  • Course Certificate