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Addressing the challenge of precise clinical and diagnostic documentation for optimal coding, profiling, and compliance in cardiology services. Bridging the gap between clinical and coding terms for improved patient care quality and regulatory adherence.
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The Challenge Documentation for coding, profiling & compliance requires specificity in DIAGNOSIS terms. Physician documentation is received in CLINICAL terms Breakdown between the two. 2 separate languages The DRG Assurance Program creates a bridge between the gap.
Our Goal • Clarify documentation in the medical record to reflect the true severity of the patient’s illness. • Achieve and maintain an administrative database that: • Accurately reflects the high quality of care provided • Ensures compliance with regulatory guidelines • Accurately reflects the complexity of our patient population • Provides a complete medical record for communication among providers
Case Mix Index Case Mix Index (CMI) • Used for resource allocation such as nursing, PA/NP staffing levels • Compare peer hospitals • Calculate Medicare reimbursements • Designate length of stay allowances • A low CMI may result from DRG assignments that underestimate the patient acuity and the actual resources used in treatment
CMS Present on Admission Reporting Requirements • CMS defines POA: present at the time of order for inpatient admission • Conditions that develop during an outpatient encounter, including ED, observation, or outpatient surgery, are considered present on admission • POA indicator is assigned to the principal and secondary diagnoses • Provider must resolve inconsistent, missing, conflicting or unclear documentation • Conditions that occur during the inpatient stay are called “hospital Acquired Conditions” (HACs) Source: CMS Manual System Transmittal 1240, May 11, 2007 Subject: Present on Admission Indicator
Clinical Documentation Update Questions about this presentation? Please contact: • Thenia Nesbeth-Blades,RN,MSN Documentation Improvement Specialist thn9003@nyp.org (212) 305-0337