welcome to the introduction to clinical documentation Improvement brought to you by aao mCP the American Association of medical coding professionals so this is uh just a brief overview to get you get your feet wet get in the pool and swim around a little bit and um and and we will we will certainly be taking deep dives into all aspects of clinical documentation and clinical documentation Improvement so clinical documentation is the backbone of Health Care well nothing in healthcare happens uh should happen without documentation okay uh it is it's Central it's essential it's critical uh it serves as a comprehensive record of a patient's medical Journey uh and and with many stakeholders many players many participants many providers uh many pieces of data and information so it goes from symptoms and diagnoses to treatments and outcomes Beyond its role as a historical record clinical documentation is a critical tool for healthcare professionals ensuring accuracy compliance with regulations uh and a delivery of quality Care in this program we will explore the fundamental fundamental aspects of clinical documentation including its importance key principles and guidelines the definition of clinical documentation and the reasons for clinical documentation Improvement so you know I I don't know if we can pigeonhole a definition to a single definition but uh but but let's start here clinical documentation refers to the process of recording patient information and Care related activities and Health Care records so that is you know that is element number one very very very basic it does encompass various forms of documentation including medical charts electronic health records progress notes diagnostic reports uh you know lab reports Imaging uh tracings what have you okay clinical documentation captures a wide range of data such as medical history physical examinations laboratory results medication orders treatment plans and patient outcomes and so uh you know and and as we go through here you're going to see uh you know each folks each spoke on his wheel plays an important part so let's look at some of the the key importance uh elements of clinical documentation it's because it's not just paperwork or not just a a data file it is the lifeblood of healthcare delivery it's importance spans various facets of the healthcare ecosystem and as we said earlier the patient's medical Journey okay and so uh number one patient safety accurate and comprehensive clinical documentation helps prevent medical errors ensuring the right patient receives the right care and uh with this module will be an audio recording uh from a practicing physician that uh I believe uh you you should listen to to really drive this back home legal and Regulatory Compliance Healthcare Providers must adhere to numerous regulations and legal requirements and they span a range of the agencies a range of reasons uh you know and proper documentation is essential to demonstrate compliance and protect against legal and other challenges reimbursement and revenue cycle inaccurate or incomplete documentation can lead to delayed or denied claims affecting a health care organization's Revenue it could also lead to you know fraud waste and abuse concerns uh and and and you know there will also be another video uh with this that I think is uh important um you know for it may not be necessarily in a reimbursement and revenue cycle uh realm but it really will uh drive home uh how an error can uh can can explode into a much bigger situation continuity of care clinical documentation serves as a mean of communication between different members of the healthcare team it allows for seamless transitions of care even when patients move between providers or Health Care settings and one of the you know I think one of the you know this is not necessarily documentation but it will I think it will you know resonate you know if you've ever seen uh somebody who has a medical alert bracelet right um you know for uh diabetes or you know you know having a pacemaker or whatever um you know that is a essential piece of communication that you know can be extremely critical at a given moment okay and so documentation is as important as that medical alert bracelet okay and quality improvement analyzing clinical documentation data helps Healthcare organizations identify areas for improvement Implement evident-based practices and enhance the overall quality of care so one of the reasons that we have this thing called CDI clinical documentation Improvement ongoing process aim seeing the accuracy and completeness of clinical documentation several reasons drive this need for CDI and as we just mentioned quality of care improved documentation supports better clinical decision making leading the higher quality patient care and of course the you know we could look at that you know turn it a quarter turn and and you know inaccurate documentation could lead to uh inaccurate or or ill ill advised clinical decisions right uh reimbursement optimization accurate documentation ensures the health care providers receive appropriate reimbursement for services rendered uh reducing Financial strain on organizations and also reducing Financial strain on those who pay for it and uh you know right now uh they're you know the federal government is the largest payer of Health Services uh in this country um and right now they are really focusing on uh fraud waste and abuse and improper payments and so it it you know you could look at it one way you can say well inpatient which is paid on a drg which relies heavily on uh you know clinical documentation to arrive at a drg and you know inpatient stays or clinic you know are typically High ticket expensive you know reimbursement type uh situations but on the outpatient basis it you know while each individual claim may not necessarily be as high ticket as an inpatient claim you have far more of them and so you know it really does you know bring things into balance and so uh you know obviously medical providers want to be paid uh what they are due [Music] those who pay for it want to pay what is due but don't want to be over paying okay and so this all comes from the clinical documentation legal protection comprehensive documentation protects Health Care Providers against legal challenges as it provides a clear account to Patient Care and data analytics and research robust clinical documentation is essential for data analysis research and population Health Management which is is is you know if you look back at covid-19 okay uh or you know any any it doesn't have to be in a pandemic or an endemic um any uh significant condition across a population uh diabetes heart disease cancers you know um is statistics Drive uh you know certain forces Within These you know to to better the treatment for these conditions Etc and so uh it's critical in all ways so what are some key principles and guidelines so effective clinical documentation is Guided by key principles and guidelines that ensure its integrity accuracy and its utility accuracy and completeness documentation must be truthful complete and free from errors and of course Nothing in life is perfect but we we you know it should be the goal to strive for error free and and not be ambivalent or complacent about errors every entry should reflect the patient's condition and uh an activity uh accurately timeliness timely documentation ensures that information is available when needed for patient care for billing for legal purposes Etc and you know another aspect of that is uh you know the further one gets from uh the point in time uh the fuzzier details will be so you know documentation should be uh should be performed uh in a timely fashion privacy and security protecting patient privacy is Paramount uh compliance with regulations such as uh HIPAA is essential legal and ethical considerations Healthcare professionals must be aware of the legal and health ethical implications of their documentation this includes informed consent Advanced directives end of life decisions also orders uh you know properly uh properly authenticated uh and valid orders just a a great number of uh legal and ethical considerations and interdisciplinary collaboration effective Health Care requires communication among different disciplines clinical documentation should facilitate this collaboration ensuring that each member of the healthcare team has access to relevant information we've all heard specialist you know a a maybe a primary care physician refers one of their patients to a specialist okay well what's the value of uh you know a patient seeing a specialist if the findings the observations the conclusions that Specialists are not you know communicated back to the primary care physician or others who may you know end up being involved in the in the process of that patient's care so CDI Specialists serve as a bridge between clinical care and many many many many administrative processes working diligently to ensure the clinical documentation is comprehensive accurate and aligned with the highest standards of care and observance and end adherence to guidelines their efforts contribute to better patient care Regulatory Compliance Revenue optimization any overall efficiency and quality of Health Care delivery so it's an important role focusing on improving the quality and accuracy of clinical documentation within Healthcare organizations the role encompasses various responsibilities aimed at ensuring the medical records accurate reflect accurately reflect that's uh you know that is if we if we could boil it down to two words accurately reflect the patient's condition the care provided and the severity of illness or conditions so Let's uh take a look at some of the key elements here uh reviewing clinical documentation CDI Specialists review medical records including Physicians notes nursing documentation diagnostic reports to identify inconsistencies gaps and opportunities for improvement in the clinical documentation and we have a a a extensive library of uh CDI modules that you know I encourage you to to you know view as many as you can uh each each it you know brings valuable Insight uh you know to specific topics uh and um and just broadens your horizons and your awareness as a CDI clarification and query when CDI Specialists identify unclear or incomplete documentation they initiate queries or communicate directly with Healthcare Providers to seek clarification and additional information this ensures the medical record accurately represents the patient's condition and treatment um it was funny I was having a conversation with somebody uh recently uh and they they said that they had been told uh that uh in the outpatient World they couldn't query the physician and I almost fell off my chair uh it is CDI is not location specific okay um you know I I told the person you know I I worked in an orthopedic practice and while I'm you know if I came across something in a record that wasn't clear or I needed more information on Etc you know it was a 10 surgeon Orthopedic practice each each surgeon had a PA so we had 20 providers but uh it was pretty common practice if I you know if I saw say Dr o uh you know had some deficiency in his record I could well I could walk down from my office to Dr O's office and say hey uh you know Mike um you know this is missing or this is unclear and you know uh is there a way you can you can make that more clear okay so that was an in-person query request um and you know I would check later that day the next day whatever the time frame you know was and and you know I would see if the situation was wrong resolved so you know that was kind of informal CDI and and that you know in uh and some medical practices that is that is the method okay and it's still CDI now you know the best practices is to to have these things documented Etc but we've got to we got to face facts uh you know in in in smaller or more familiar or you know uh certain environments a verbal uh you know a request for clarification um can still occur educating Healthcare Providers CDI Specialists educate Health Care Health Care Providers I mean importance of accurate documentation coding guidelines and the impact of documentation on patient care reimbursement and quality metrics they facilitate ongoing training to enhance clinicians understanding of clinical documentation's role in healthcare let's face it folks medical providers have a lot on their shoulders they keep a lot of balls in the air at one at one time and their purpose their mission the reason they do what they do the reason they decided to get into what they do is patient care okay so it's understandable that uh you know some of the you know peripheral requirements uh you know are not their first priority in their heart and soul their mind Etc but they are still required and they still must be complied with and so CDI Specialists can really help uh you know reinforce uh you know some of these things to Providers and help them you know integrate them into their workflows so that they are not obstructive they're not a burden coding compliance a CDI Specialists work closely with medical coders to ensure that Diagnostic and procedural codes assigned to the patient records online with clinical information documented uh accurate coding is essential for proper reimbursement and accurate data reporting so one of the things that you know separates a medical coder from a CDI person is is you know again it's the CDI is a an liaison okay and you know and and really you know it really has two uh essential tool kits the clinical knowledge and clinical you know uh verbiage click clinical understanding and then the the other you know it doesn't have to necessarily be coding it could be regulatory it could be other things uh but but you know there are liaison between Clinic clinical you know clinicians uh practitioners and other stakeholders okay uh and they specialize in forensically uh you know you know reviewing the records and identifying opportunities for uh Improvement okay uh severity and risk adjustment the CDI specialist assess and and document the severity and complexity of patient conditions this information is used for risk adjustment models which can re-impact reimbursement to uh Health Plans Quality Reporting and population Health Management quality improvement they contribute to quality improvement initiatives by identifying Trends and patterns and clinical documentation that may point to areas needing Improvement uh this can lead to enhanced patient care and compliance equality standards and so again you know uh as I said you know CDI Specialists are Liaisons at too many stakeholders and you know in the quality world you know you know you may have heard of something called hedis and if you haven't uh you know I'm not going to give you a course to stop here and give you a course in hedis but that is a a significant quality driver as others are under macro et cetera um and so CDI uh Specialists really do help optimize quality measures uh through their efforts to uh to improve documentation okay data analysis and Reporting CDI Specialists and now clinical documentation data to identify opportunities for process Improvement adherence to best practices compliance with regulatory requirements they may generate reports and share findings with Health Care leadership these are called metrics and we'll certainly delve more into metrics down the road here uh again Regulatory Compliance uh compliance regulations concerning the clinical documentation compliance that complies with legal and regulatory requirements such as those related to health insurance uh portability and accountability act HIPAA uh and Medicare Medicaid guidelines uh cop conditions of participation okay and there are some cfrs code of federal regulations that specifically mandate uh certain uh you know record uh uh requirements patient care enhancement and I I you know I mean this may be labeled number nine but it you know I I think patient care is number one always right improve clinical documentation translate into better communication among Health Care Providers resulting in more informed clinical decision making patients safety and continuity of care and again uh please listen to the three-minute uh audio uh from uh uh our physician uh I think it's really important supporting revenue cycle CDI Specialists pay a role in optimizing revenue cycle management by facilitating accurate coding and accurate coding results in accurate reimbursement uh reducing claims denials enhancing the billing process and again you know it keeps in Balance uh providers getting paid what they should while payers paying what they should and keeping those things aligned continuously staying current with updates in medical terminology coding systems Healthcare regulations is crucial for CDI Specialists to perform effectively in their role and again as a liaison you know um providers are not going to you know make it their their number one priority to stay up on all these uh there's just so many different regulations you know even in the clinical space uh you know there's there's regulatory changes uh industry standards uh that that would they would certainly focus on first before uh administrative so again um you know CDI Specialists can be the shepherd uh you know of the of the clinical flock there interdisciplinary collaboration collaborating with uh various Healthcare professionals including Physicians nurses coders administrators is essential to achieve accurate clinical documentation and improve patient outcomes and you know we're gonna you know patient outcomes number one uh compliance and and other outcomes uh number two three four five but all equally important but of course um you know there's there's nothing uh there's there you know without optimal outcomes uh and and patient safety and accurate and uh you know appropriate patient care uh there's no point to anything else success in the field of clinical documentation Improvement requires a constellation of Knowledge and Skills a combined clinical understanding Regulatory Compliance effective communication and collaborative teamwork and as I you know you know uh a medical coder I know medical coders who never talk to anybody okay uh especially in this world of remote work they they see a record they code a record okay uh that is one distinct difference between a a CDI specialist uh and and you know um and and sometimes you know in this field uh there is no you know there's no compartmentalization you know absolute compartmentalization a a medical coder can you know wear both hats be medical coder and CDI can be medical coder and medical biller you know so uh there's many in this field who wear multiple hats but you know just focusing on the the the role of clinical documentation Improvement Specialists uh communication is effective communication is uh and collaboration is critical success in the field of clinical documentation Improvement requires a multi-faceted approach that comply combines that clinical understanding the knowledge of regulations and and and being uh Vigilant compliance effective communication and collaborative teamwork these are all uh again these are all uh keys to success in the role of a CDI so uh here are some L key elements for achieving success striving for knowledge of clinical understanding uh CDI Specialists must possess a strong foundation in clinical medicine or you know look you know don't confuse a CDI with being and you know at the level of a clinical practitioner okay uh but but you know you can't you can't do this without a a foundation in and you can't do this with longevity without learning something from each case that you work on so so you you're constantly building knowledge but you have to understand disease processes treatment modalities medical terminology you know all of these things so you know clinical knowledge is essential for this thing that uh you know this role that has clinical in its title right um regulatory requirements and guidelines so Proficiency in health care regulations and guidelines uh you know icd-10s you know procedures drgs what have you and you know and you know look if you're an outpatient CDI you may not necessarily need to uh you know you may not necessarily work with drgs you may work with um apcs right uh but it's it's it essential to have these regulatory requirements and guidelines okay uh and and staying up to date okay and that's again remember the liaison uh you know it's it's the role of a CDI to to be that uh that Watchman for or watch Person for uh changes so that they can collaborate communicate these two uh providers and integrate them into workflows and so you know remaining current on changes so you know whether you you know whether it's the uh um you know industry Communications whether it's you know CMS uh news uh portal um you know what have you okay uh remaining current on changes is uh is is essential communication communication with stakeholders absolutely you know if if you are not interested in communicating or or not effective in communicating uh it's gonna be a long road CDI Specialists must engage with various stakeholders okay Physicians nurses administrators coders uh to achieve this uh this thing called CDI and you know you know the CDI used to be clinical documentation Improvement and now uh some have adopted the uh the term clinical documentation integrity and uh it's both you know um and so again you should uh you you to to achieve that we must have communication and collaboration it's a team effort okay I remember you know there's no point for a liaison if there's if there's no liaising uh so you know a a a uh CDI specialist is a collaborator okay uh is the is the ringleader of sorts okay uh attention to detail uh absolutely critical okay um cdis must be meticulous uh to to whatever you know comes their way uh and it can be such a spectrum of different things you know from one record to another so uh but they must be able to uh identify gaps inconsistencies [Music] um you know uh contradictions uh you know ambiguities what have you so meticulous attention to clinical nuances because even minor inaccurities can impact patient care and reimbursement uh data driven insights as I mentioned we'll talk more you know throughout the program about metrics utilizing data analytics and Reporting tools to identify Trends and patterns in clinical clinical documentation data-driven insights can guide targeted Improvement efforts and highlight areas for focus and um one of the things that we will cover is What's called the case mix index uh and that is a one of many metrics uh and so you know we will certainly dive into uh data-driven insights in the program Improvement okay and uh generally you know cdis are all about the commitment to quality improvement uh they have to be somewhat of a Statesman a state's person they have to be somewhat diplomatic uh they have to be you know aware of many different hats a motivator Etc to uh to uh engage clinicians to to Foster that same commitment to quality improvement so uh embracing a continuous Improvement mindset and acting on identified areas for enhancement providing feedback to colleagues and seeking opportunities to refine documentation practices and uh you know again you know when you have a list of things you you know if it's an ordered list numbered list you know number nine does not necessarily mean last or or at least less important uh ethical practices uh for example uh when constructing a query there's ethical concerns ethical vigilance it must be obtained maintained so maintaining a highest ethical ethical standards in the CDI uh among them are respecting patient privacy and confidentiality and ensuring that all documentation is accurate and honest so uh what should be in clinical documentation and and this is certainly not a complete list uh you know but uh you know it's kind of a categorical uh you know overview uh certainly physical evaluation uh clinical evaluation so you know physical evaluation would be you know direct observation of uh patient and and and and and their habitus okay um clinical evaluation would certainly be you know uh you know reviewing um either Labs or you know things that that are recorded that are not necessarily a direct observation of the patient itself diagnostic evaluation uh results of different uh diagnostic studies whether they be Labs whether they be uh you know Imaging uh Electro physiologic uh like EKGs or something like that uh therapeutic should be you know all therapies uh you know from medications to physical therapy to you know Psychotherapy whatever all Therapeutics should be uh you know listed uh accurately in the clinical documentation the level of care required okay that should be certainly included in a documentation and assessment okay um the treating or attending provider is responsible for uh in that particular instance providing their assessment updating an assessment uh you know what have you uh that should not be a uh spin of the wheel uh or the magic eight ball for uh anybody else to uh arrive at clinical criteria and indicators documentation uh diagnostic options and results and therapies all of these should be in the clinical documentation uh one final you know uh uh starting point uh discussion is you know uh people often ask well what's the difference between a CDI specialist and an auditor okay and this kind of goes back to that statement that often uh there's overlap um you know often there in in healthcare uh especially in the uh you know administrative and uh billing reimbursement documentation you know uh sometimes people wear several different hats and so there's overlap but um you know there's probably you know five different um you know distinctions between an auditor and a CDI specialist and uh the first is focus and purpose CDI Specialists uh primarily focus on improving equality and accuracy of clinical occupation in the records their goal is to ensure that the documentation accurately affects the patient's condition treatments and severity of illness their work contributes to better patient care accurate coding and compliance with regulations and you know and again you can say the same thing for otters but Auditors on the other hand are responsible for exam examining Healthcare documentation Financial records and coding for the purpose of evaluating compliance with regulatory requirements assessing Financial accuracy identifying areas of potential Fraud and Abuse and so you know one is and we'll talk about this uh in number three timing uh timing and so you know the these may seem uh you know number one focus and purpose um you know uh if you look at a team a sports team they're they all may have different functions on a team but the the goal is to win the game right uh role in documentation Improvement uh the CDI Specialists work proactively here's you know proactively with clinical staff to clarify and enhance clinical documentation they often collaborate with positions and nurses to ensure accurate and complete records their focus is on improving the quality of clinical documentation for better patient care and reimbursement uh Auditors typically you know buy by Design typically have this wall between them and their you know their their subject uh at least during the process Auditors are typically engaged in retrospectively to engage retrospectively to review documentation and financial records They assess compliance accuracy and adherence to coding and billing guidelines their role was often associated with financial oversight and Regulatory Compliance and and you know they it's not that they don't you know provide feedback Etc but the CDI Specialists are are Provo you know again Proactive or uh you know engaged in the process of uh Improvement you know in real time Auditors are kind of looking back road retrospectively looking for Trends looking for red flags Etc so you know Auditors you know probably you know we're gonna move to timing here and number three but timing is is one major distinguishing factor that you know identifies a CDI and an otter uh independently so timing of Engagement CDI Specialists are typically involved in the health care process concurrently okay or concurrently with patient care they aim to address uh documentation issues as they arise to prevent inaccuracies or gaps while Auditors are often engaged retrospectively after patient care has been provided and claims have been submitted uh their focus is on conducting post payment or or prepayment reviews for compliance and financial accuracy also kind of a a granular thing too uh you know a CDI specialist is you know uh you know one of the one of the essential terms in the philosophy of a CDI specialist is case Okay uh you know they're they're looking at Case by Case by case where Auditors are looking at more of a uh a a body a universe of of encounters uh to you know uh measure overall accuracy overall Trends Etc so they look at more of a universe of of data where CDI Specialists look at uh you know Case by Case by case uh the way that uh that you communicate and collaborate uh CDI Specialists engage in frequent communication collaboration with clinical staff that's one of their main roles okay they work closely with the team to ensure accurate documentation and provide education on best practices Auditors May communicate with various stakeholders including coding professionals billing staff you know providers Etc but their interactions are generally less frequent uh and uh and and they're more uh again uh you know uh on a reporting basis okay and goals and outcomes CDI Specialists the primary goal of CDI Specialists is to enhance Patient Care by improving the quality and accuracy of clinical documentation their efforts can lead to improved patient outcomes appropriate reimbursement and compliance with quality metrics Auditors aim to identify financial and Regulatory Compliance issues potential Fraud and Abuse uh and areas where corrective actions may be needed to you know overall uh you know policies and procedure change Etc so um you know a lot there is you know there's some gray area there's some overlap but these are just some general uh differences between a CDI specialist and an auditor so that is our uh introduction and uh we are going to be certainly diving much deeper into uh these different uh aspects of clinical documentation I hope this gives you a good starting point and we will see you in the next module