ICD-10 Advice From Kelli Estes

CDI Review Notes – How much is too much?

Compiling a “CDI version” of the documented H & P is too much!

Inevitably, CDSs need to make notes to prompt their thoughts about the cases they review, but there is much better use of time and productivity by honing in on what lacks in documentation rather than copying what is already well stated.

In defense of a CDS “newbie”, writing down more clinical content in the review notes is understandable and certainly expected while training. However, as the CDS matures, irrelevant content will become much clearer thus resulting in less daily review notes.

The CDS must gain perspective regarding the intent of review notes. The logic behind review notes is to assist any CDS with being more efficient in their work not a burdensome process eating away excessive amounts of time. In reality, CDI review notes are intended to serve as a quick reference to the potential need for pursuing improved documentation via physician clarifications.

It is important to note that the vast majority of CDSs entering the marketplace are nurses. Nurses are trained to give and receive shift reports encompassing a thorough overview of the patient’s active medical problems as well as past medical history, treatments, labs, x-rays, diet, activity, etc. This is part of a process embedded into the standard training for nurses. As a nurse, it is difficult to embrace different methods of note taking as it relates to the world of CDI. Like any learned process, it is difficult to make changes.

Additionally, nurses are not coders. However, they need a “working knowledge” of coding to do their job well. Because of this, they sometimes feel the need to write more than what’s necessary. It helps to have a strong “working knowledge” of coding to understand how certain type notes will help compliment their work when identifying the need to obtain more specific physician documentation.

But, in the end, it would be most helpful to just keep it simple and review more cases!
Kelli Estes, RN, CCDS

http://cditips.com/excessive-note-taking-less-reviews-decreased-productivity/

ICD-10 Implementation Pushed Back

The HHS has officially pushed back the ICD-10 implementation deadline because they felt like it would maximize benefits to providers and minimize costs of delay. After weighing both the risks and consequences, the HHS felt that the delay provided the most regulatory balance. Even though the deadline has moved back, there is a great sense of urgency to prepare for the coming changes. Officials have stressed that hospitals need to begin making strides towards the new system.

Children’s hospitals face challenges that are unique to the field of pediatrics. With the implementation of ICD-10, there will be a new set of difficulties for coders and billing staff. An increased number of codes can mean greater specificity and those proficient in ICD-9 could have trouble adapting to the changes. Many children’s hospitals are seeking out the help of experienced consultants to assess their current state and prepare for the new system. Officials recommend not waiting, but instead, beginning a PDI program prior to ICD-10 implementation. This, in addition to training specifically for the new system, gives children’s hospitals the the greatest chances for a smooth transition.

DCBA provides on site education to prepare staff for ICD-10. They have also created CDI programs tailored to the unique field of pediatric medicine. DCBA brings years of experience from doctors, nurses, coders, and documentation specialists to consult with children’s hospitals and implement proven strategies for success. There has never been a better time to begin a PDI program than now. With comprehensive software and a detail oriented approach, DCBA brings real results to pediatric healthcare organizations.

Pediatric ICD-10 Training

Healthcare providers need to be ready to make the transition to ICD-10. In order to make the shift successfully, it is essential for physicians, nurses, coders, CDI professionals all must be on the same page to be able to best work together. The best option for providers is to seek out clinical documentation review and improvement.

Recent studies have shown that only about 37% of current physician documentation would meet the standards of ICD-10. For pediatric healthcare organizations who do not have a CDI program in place already, it is an essential step to gain results and streamline documentation efforts. Beyond getting ready for the transition to the new challenges that ICD-10 poses, CDI programs provide numerous other benefits which include: improving the quality of care and security of patients, more concise public reporting, reduction of denials and audits, less coding delays and physician queries, and an improved case mix index.

DCBA, a clinical documentation improvement solutions provider, has the experience and dedication to provide real results for your organization. With hundreds of success stories helping hospitals, clinics, and pediatric groups, DCBA brings in their experts to work with you. Onsite education is available to address the specific challenges and issues faced with ICD-10, and how they differ from ICD-9. In addition, electronic resources are available to staff to gain full benefit of the educational material. Pediatric healthcare providers all over the country have realized the benefits that ICD-10 training and CDI programs from DCBA have to offer, isn’t it time for you?

ICD-10 Training Programs

ICD-10 training is becoming more and more relevant for pediatric hospitals. This change will create some new documentation challenges for coders and clinical documentation specialists. With the new standards differing from ICD-9, an increased number of codes will allow for more specificity. This could mean that those who were proficient in ICD-9 could have difficulty working through the new guidelines. Healthcare providers who have not yet put in place a strategy to prepare for the changes must realize that the clock is ticking.

In addition to the new challenges with ICD-10, clinical documentation improvement programs can help children’s healthcare organizations increase case mix index, billing accuracy, and hospital profiles. Documentation directly supports coding which can affect hospital reimbursement and revenue. Starting a CDI program could be a key survival strategy for pediatric hospitals. Education is an essential first step towards finding solutions in pediatric clinical documentation improvement.

DCBA helps pediatric healthcare organizations with on site education as well as electronic resources to get ready for ICD-10. They can also analyze processes and put strategies into place that help create quality documentation results. Keeping staff on the same page is important so giving the proper tools to physicians, nurses, and billing and coding specialist provide a cohesive effort toward more accurate documentation. Children are not adults, and thats why DCBA has created CDI programs specifically for children’s healthcare.

Getting Ready For ICD-10

Most healthcare providers are bracing for ICD-10’s implementation. Many organizations have taken steps to prepare for the coming shift, but there are still groups who need assistance. Two keys for preparation are to gain ICD-10 training for employees and seeking out a clinical documentation improvement program to strengthen understanding and gain consistency.

ICD-10 will mean greater specificity for documentation and coding staff. Those who are proficient in ICD-9 may have difficulties with ICD-10 without necessary preparation. For instance, diabetes as a condition has expanded to over 200 codes, a significant leap from the 60 something codes prior. But, because our practices have changed greatly since ICD-9 was implemented in the late 70’s, the need for a new system is upon us (some would say overdue.)

The greater specificity of ICD-10 isn’t frightening, it is essential and will be much better for health care in the long run. DCBA, a clinical documentation improvement company, has been helping clients all over the country prepare for the coming changes that ICD-10 will bring. By working directly with staff with industry professionals, they provide comprehensive solutions to get pediatric hospitals prepared. Documentation improvement programs hold many advantages that can lead to increased compliance, productivity, and revenue.

Pediatric Documentation Challenges

The field of pediatric healthcare is constantly evolving, bringing with it new ideas, practices, and procedures. Though the future constantly brings new things, accurate clinical documentation will always be a necessity. In pediatric documentation, there is a vast amount of data generated every day. With multiple data streams, it is not uncommon for information to get lost in the pipeline or misinterpreted. Communication is key for accurate data. When physicians, nurses, CDI specialists, and coders are on the same page, true improvements in documentation can be made.

DCBA provides consultation and education for pediatric hospitals seeking to enhance their current clinical documentation practices. With ICD-10 implementation approaching, there has never been a better time to begin streamlining the documentation process. Comprehensive software, results based strategies, and a detail oriented approach make DCBA a leader in the field of pediatric clinical documentation improvement. They have helped hospitals across the country to achieve their goals and enhance their profiles, increase CMI, and improve quality scores.

Benefits Of PDI

One of the most important factors in developing a more effective documentation program is that both the physicians and administrative staff see the value of improving the process. It is essential for hospital administration and physicians to work together on common goals to have a successful program. PDI programs can be tailored to operate with an organization’s existing program, implementing strategies where needed to help increase both productivity and profitability.

Children’s conditions differ from those of adults. Because of this, accurate documentation of pediatric conditions is important for proper coding. By seeking solutions to create more efficient documentation, pediatric healthcare organizations can gain increased compliance, improve their CMI, and enhance their profile. Pediatric clinical documentation improvement programs can help create more consistency across board. It is beneficial for children’s hospitals to seek out the experience of a PDI company who understands their needs.

DCBA, a CDI solutions provider, knows what it takes to foster a successful documentation strategy. By consulting with professionals across the country, they can stay up to date with current trends, issues, and news in the industry. DCBA can provide on site education as well as online resources for staff. With years of experience creating solutions for pediatric healthcare organizations, they bring the combined knowledge of industry professionals to find the right strategies for any organization.  

Pediatric Clinical Documentation For Children's Hospitals

Many who consult with physicians and healthcare organizations treat pediatric concepts the same as they would adult acute care. They feel that the same principles apply across the board. This could not be farther from the truth. Children are not adults. Their illnesses and conditions vary from those in the adult and geriatric age groups. Children’s cardiologists are not going spend much time becoming educated on ischemic heart disease. Pediatric healthcare organizations need solutions to issues that they face in their sector.

Documentation plays a critical role in pediatric hospitals. Streamlining documentation efforts can create numerous benefits for patients, physicians, administration, as well as billing and coding staff. PDI programs can lead to an increase in patient quality scores. Greater documentation can lead to physicians and coding staff capturing more information than they would have before. Administration can see increased revenue, easier filtering and resolution of claims, and improved profiles. Pediatric clinical documentation programs can lead to increased profitability and compliance for organizations who take steps towards greater accuracy and proficiency in documentation and coding.

DCBA has worked with hundreds of hospitals and healthcare organizations to implement successful clinical documentation improvement programs. Their clients include some of the largest pediatric care providers in the country. With years of experience in medicine and clinical documentation consulting, DCBA brings the experience of leading industry professionals to tackle the specific needs that pediatric healthcare organizations face. They work with physicians, nurses, mid level providers, and other medical professionals to implement a cohesive hospital wide pediatric clinical documentation improvement program.

Are You Ready For ICD-10?

ICD-10 training is becoming more and more relevant for pediatric hospitals. This change will create some new documentation challenges for coders and clinical documentation specialists. With the new standards differing from ICD-9, an increased number of codes will allow for more specificity. This could mean that those who were proficient in ICD-9 could have difficulty working through the new guidelines. Healthcare providers who have not yet put in place a strategy to prepare for the changes must realize that the clock is ticking.

In addition to the new challenges with ICD-10, clinical documentation improvement programs can help children’s healthcare organizations increase case mix index, billing accuracy, and hospital profiles. Documentation directly supports coding which can affect hospital reimbursement and revenue. Starting a CDI program could be a key survival strategy for pediatric hospitals. Education is an essential first step towards finding solutions in pediatric clinical documentation improvement.

DCBA helps pediatric healthcare organizations with on site education as well as electronic resources to get ready for ICD-10. They can also analyze processes and put strategies into place that help create quality documentation results. Keeping staff on the same page is important so giving the proper tools to physicians, nurses, and billing and coding specialist provide a cohesive effort toward more accurate documentation. Children are not adults, and thats why DCBA has created CDI programs specifically for children’s healthcare.

Advantages of Pediatric Clinical Documentation Programs

The field of pediatric healthcare is constantly evolving, bringing with it new ideas, practices, and procedures. Though the future constantly brings new things, accurate clinical documentation will always be a necessity. In pediatric documentation, there is a vast amount of data generated every day. With multiple data streams, it is not uncommon for information to get lost in the pipeline or misinterpreted. Communication is key for accurate data. When physicians, nurses, cdi specialists, and coders are on the same page, true improvements in documentation can be made.

DCBA provides consultation and education for pediatric hospitals seeking to enhance their current clinical documentation practices. With ICD-10 implementation approaching, there has never been a better time to begin streamlining the documentation process. Comprehensive software, results based strategies, and a detail oriented approach make DCBA a leader in the field of pediatric clinical documentation improvement. They have helped hospitals across the country to achieve their goals and enhance their profiles, increase CMI, and improve quality scores.

Pediatric Clinical Documentation Improvement Programs

Clinical documentation improvement programs employ consultants to review documentation and provide feedback to physicians, nurses, and other professionals. The information given is designed to fill in spaces in documentation by answering questions, improving quality scores, and measure overall patient management. Pediatric hospitals require the knowledge of consultants who understand the specific issues that they face. With the help of an experienced company, children’s hospitals can streamline their documentation efforts to provide maximum results. DCBA has created innovative pediatric solutions to help children’s hospitals get the most out of their documentation.

DCBA is a pediatric clinical documentation improvement solutions provider based in Atlanta, Ga. By helping clients all over the country, DCBA stays current with industry trends and changes. They help to educate pediatric healthcare professionals on the coming changes with ICD-10 to better prepare them for a smooth transition. By designing a program that specifically addresses pediatrics, they hone in on the real issues at hand and tailor their approach to your organization. When looking for solutions to documentation, coding, and ICD-10 preparation, look no further than DCBA.

Clinical Documentation News

For those in the clinical documentation improvement industry challenges are faced on a daily basis. Sometimes it can be tough to keep up with other happenings in the industry when you are consumed by tasks at hand.  Fortunately, there is a resource that can help to keep you in the loop with what is going on across the CDI spectrum. CDI Monthly provides valuable information each month to those in the clinical documentation industry-it's also free and easy to sign up. Simply provide your email address and you will receive the publication each month. What are you waiting for? Sign up today!

Clinical Documentation Improvement News

Looking for the latest news in the world of clinical documentation improvement? Check out the monthly newsletter created by DCBA. Every month, DCBA sends out a newsletter, free of charge, to those who have signed up for the mailing list.

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What Is a Pediatric Clinical Documentation Program?

Clinical documentation improvement programs employ consultants to review documentation and provide feedback to physicians, nurses, and other professionals. The information given is designed to fill in spaces in documentation by answering questions, improving quality scores, and measure overall patient management. Pediatric hospitals require the knowledge of consultants who understand the specific issues that they face. With the help of an experienced company, children’s hospitals can streamline their documentation efforts to provide maximum results. DCBA has created innovative pediatric solutions to help children’s hospitals get the most out of their documentation.

DCBA is a pediatric clinical documentation improvement solutions provider based in Atlanta, Ga. By helping clients all over the country, DCBA stays current with industry trends and changes. They help to educate pediatric healthcare professionals on the coming changes with ICD-10 to better prepare them for a smooth transition. By designing a program that specifically addresses pediatrics, they hone in on the real issues at hand and tailor their approach to your organization. When looking for solutions to documentation, coding, and ICD-10 preparation, look no further than DCBA.