Pediatric Hospitals Transitioning To ICD-10

Having a poor transition into ICD-10 could lead to difficult repercussions. These could include cash flow problems, increase in claims or denials, unintended changes in payment, and backlogs in billing and coding.

Gaining education for staff and putting into place a pediatric clinical documentation program can help organizations make the shift easier. With a proven record of success, DCBA helps children’s hospitals and pediatric healthcare organizations streamline documentation with time tested strategies. DCBA’s CDI program specifically designed for pediatric health care can increase case mix index, offer improved coder efficiency, and reduce noncompliance. Their solutions in pediatric clinical documentation have helped hundreds of companies across the U.S., let DCBA go to work for you and provide comprehensive strategies that gain real results.

ICD-10 Training Atlanta

With the specificity soon to be required by ICD-10, there are many hurdles that pediatric healthcare organizations will face. Fortunately, there are options for physician and coder education that can ease the process. Aside from the day to day challenges that hospitals face, there are long term challenges that arise over time. Many of these challenges may lie within the realm of pediatric clinical documentation.

When documentation is lacking, many other areas can suffer. Pediatric hospital revenue can be affected, as well as quality scores and case mix index. The key is for organizations to realize is that through a cohesive effort, documentation can be improved with the help of experienced CDI professionals. DCBA incorporated, a clinical documentation improvement solutions provider, helps pediatric hospitals to find the proper solutions to their clinical conundrums. With the experience of skilled physicians, consultants, nurses, and CDI specialists, DCBA brings results based strategies to help hospitals gain more accurate documentation.

Clinical Documentation Improvement For Pediatric Hospitals

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.

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 healthcare organizations, they bring the combined knowledge of industry professionals to find the right strategies for any organization.  

Clinical Documentation Improvement In Hospitals

CDI, as it is typically used in hospitals, utilizes consultants who assess clinical documents and provide responses to physicians, says Dr. Robert Gold, CEO of DCBA. The responses given are intended to provide solutions to issues with documentation including questions about the coding used, quality, and management of the overall care of patients. As Dr. Gold Says, “Paint the picture of the patient properly with words, so the coder can paint the same picture with codes.”

Healthcare organizations can realize positive changes in accuracy and compliance. Take a look at what this CDI Liaison Nurse had to say about working with DCBA’s team:

I am still amazed everyday at the intensity and level of cooperation with documentation from the majority of our physicians. And I don’t take credit for it. It is an expectation of the leadership here, the staff follow through willingly, and the rest just happens. The physicians are pretty accessible on the floors so we are able to make frequent contact with them and educate as needed. We even had a metabolic doc come up to us and ask how to document an unusual condition that was present on admission. Even the pediatric surgeons answer our queries. And we are presenting to the new docs coming on board at the end of the month. So life here is good.

Clinical Documentation Improvement Pediatrics

Pediatric clinical documentation improvement programs play a key part in fostering greater documentation accuracy and resolving issues faced by children’s hospitals. Millions of dollars are lost each and every year due to improper or inaccurate billing. Physicians, nurses, coders, and administrative staff need to be on the same page in order to produce maximum efficiency in documentation. Because the needs of children’s hospitals are unique, they require CDI programs that address the challenges that they face.

                                     

With the experience of helping hundreds of organizations and a skilled consulting team of doctors, nurses, and coders, DCBA brings it’s experts in to address the issues that children’s hospitals deal with. By working directly with hospital staff and providing on site education as well as online resources DCBA delivers strategies that are specific to each organization. With the help of CDi Trax software, documentation specialists can streamline their processes and better manage their workflow. DCBA strives to provide solutions and results with the highest level of service in the industry.

Clinical Documentation Improvement News

If you are looking for the latest news and trends in the clinical documentation improvement world, check out the monthly CDI newsletter from DCBA. You can sign up to join the mailing list and receive updates each month. This newsletter is sent each month to professionals all over the nation and has become an invaluable resource for those in the clinical documentation improvement field. For real time discussion on the industry, check out the CDItalk forum as well. There you can voice your opinions, ask CDI questions, and gain insights from the skilled consultants at DCBA.

                                                           

Clinical Documentation Improvement: Coding Acute Respiratory Failure

Appropriate use of the term “acute respiratory failure” has become a hot topic recently. Some well-meaning CDSs, billers and doctors have fallen into the trap of using the term in order to bill at a higher level. This is an especially timely topic with the advent of Value Based Purchasing. At a recent client site, the pulmonary intensivists were using the term 100% of the time in their post procedure patients on a ventilator. I met with these doctors the next morning during rounds. We saw 4 patients, three of which had no problems being weaned off the vent using standing orders. The fourth patient arrested during the night after being weaned from the ventilator and had to be re-intubated. The time the intensivists spent with the first three patients was very brief. The decision making and time spent with the fourth patient was obviously more intense. It was clear that the fourth patient had indeed had an episode of acute respiratory failure. The ventilator management of the other three patients was just an integral part of the procedure and therefore use of the term “acute respiratory failure” would be inappropriate. Rounding with these doctors was incredibly beneficial. This is a very effective way to resolve documentation issues; reviewing their patients’ charts in real time.

Kelli Estes, RN, CCDS