Outpatient clinical documentation improvement initiatives are gaining interest with providers as healthcare delivery models are transforming away from Fee-for-Service to Fee-for-Value and more third- party payers are incorporating some measure of risk adjustment through HCCs into the scheme of reimbursement. An effective outpatient CDI program embraces the vision, goals and objectives of improving the quality of clinical documentation that accurately reflects and reports the communication of actual care provided. Communication of patient care tells the true story of patient beginning in the physician’s office at every patient encounter, particularly considering the fact most of services performed in the hospital based setting are driven by documentation and physician orders generated in the physician’s office. Outpatient CDI is predicated upon enhancing and furthering clear, concise, consistent and complete documentation that answers and addresses the what, where, how, why, what for, what am I thinking, where, and what am I going to do when I get there conceptual thought process as an integral part of physician clinical judgment, medical decision making and analytical problem-solving skills. Simply put, outpatient CDI is not predicated upon strict diagnosis capture; instead it is predicated and founded on principles of best practice standards of clinical documentation supporting the communication of patient care extending from physician office encounter to physician order, service delivery, charging, coding, billing and the use of the diagnostic workup and treatment in the physician’s management of the patient.
By attending this webinar, attendees will learn first-hand common misconceptions and misunderstandings of what outpatient CDI represents and what constitutes the fundamentals of outpatient CDI goals and objectives, driving the development and implementation of meaningful programs that achieve meaningful sustainable improvement in real documentation beyond diagnosis capture. Material covered will outline, define and provide detailed direction on how best to organize, plan, develop, solicit administration and medical staff buy-in, roll out and measure success of an outpatient CDI program. This webinar will provide an encompassing roadmap to develop and implement an effective outpatient CDI program, closely aligning and integrating with the revenue cycle while facilitating alleviation of avoidable medical necessity denials and enhancing of patient satisfaction.
Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM
Senior Consultant, Federal Advisory Partner
Glenn Krauss is a long time Revenue Cycle Professional with progressive hands on experience in all facets of the revenue cycle. He possesses a high energy level and passion for clinical documentation improvement initiatives that drive physician engagement in truly wanting to learn and acquire best practice standards of clinical documentation supporting communication of patient care. Glenn brings more than 20 years as a professional in the Health Information Management arena; previously, he held executive and consulting positions including Director of Enterprise Solutions, Revenue Systems Manager, CDI Director, Director of Case Management and Revenue Enhancement, Director of Health Information Management, and Data Quality Manager with major US hospital and health systems nationwide. Glenn’s decades of experience working with physicians to improve their understanding of critical points of clinical documentation led him to a deep appreciation of what is necessary and appropriate to accurately and effectively capture the physician’s clinical judgment, medical decision making and thought processes required to best support medical necessity, charge capture and integrity, and communication of patient care reflective of quality cost effective value based outcomes.
1.0 – Clinical Data Management