Ensuring Compliance and Accuracy: Clinical Documentation Improvement Tips

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Ensuring Compliance and Accuracy Clinical
Documentation Improvement Tips
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• As healthcare providers, you dont need us to
  explain to you why clinical documentation
  integrity is such a crucial part of the overall
  patient experience whether thats for generally
  streamlining your operations or even just
  ensuring all of your documentation stays
  accurate.
• Having said that, this is definitely one aspect
  of medical billing/coding that the practices with
  larger amounts of resources have an easier time
  with and as such, its the small medical
  practice owners that find it the most challenging
  to implement a proper clinical documentation
  improvement program (often referred to as a CDI
  program) given how strapped for staff and time
  they can be.
• Still, this isnt something you want to gloss
  over when running a medical practice (regardless
  of your size) simply because of how big an impact
  it can have on improving patient care and
  hospital reimbursement.
• So, over the course of this article, well be
  taking a look at some of the more basic
  fundamentals of what CDI actually is and how you
  can improve it within your practice including
  how outsourcing your medical billing and coding
  services to a third party company like PMN can
  help.

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The Importance of Clinical Documentation Integrity

• Clinical documentation integrity (CDI) is
  obviously important for a few different reasons
  when you need accurate medical records, so lets
  break down a couple of these now
• Firstly, and perhaps most importantly, having a
  CDI program is generally going to ensure that all
  of the coded data youre collecting from
  your patients is actually being recorded
  correctly. Now, naturally, the main benefit from
  this is that youre typically able to provide an
  all-around better service to your patients, but
  its worth mentioning how much of an impact this
  can have in diagnosis-related groups (DRGs) and
  hospital reimbursement, too.
• Aside from this, though, quality clinical
  documentation tends to leave a positive impact on
  any given patients clinical status given that
  you and all your physicians are able to make much
  more informed actions for a patients treatment
  plan when it comes to medical decision making
  which ultimately means the quality of care is
  going to be better.
• Lastly, accurate documentation is going to make
  the whole documentation process much smoother in
  general, so youre also able to reduce a lot of
  those errors that might be messing up your claim
  submission process when getting reimbursed.

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Tips for Clinical Documentation Improvement

• Staff Training
• Generally speaking, the first step to actually
  improve clinical documentation within your
  practice is always going to be providing a bit of
  extra training to your clinical documentation
  specialists.
• Naturally, this can be a bit tricky for some of
  the small practices out there that cant always
  justify the cost, but ultimately, just make sure
  that all of your CDI professionals know what
  their job is when it comes to maintaining medical
  records and generally being up-to-date with all
  the latest coding guidelines (because they change
  fairly frequently).
• Clear Guidelines
• Try to set a few different documentation
  guidelines and protocols so that your medical
  staff can stay consistent throughout their work.
• Regular Audits
• Its always good practice to audit your medical
  record documentation regularly so youre able to
  take a look at which areas could still do with
  some improvement.

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Outsourcing Medical Billing and Coding Services
to PMN

• Whether its handling your A/R days or even
  providing you with progress reports, PMN are
  generally a wise choice when youre looking for a
  medical billing and coding specialist. Still, PMN
  also have over 20 years of experience with CDI,
  so lets walk through a few reasons why they
  might be able to help your practice
• Expertise
• Among the rest of their specialties, PMN have
  plenty of clinical documentation integrity
  specialists as part of their team all of which
  are well-versed when it comes to medical
  documentation and CDI programs in general.
• Efficiency
• Even outside of the CDI programs, outsourcing
  your medical billing and coding needs to PMN is
  generally going to streamline the rest of your
  practices operations, too ultimately letting
  your physicians save time and move back to
  focusing on the quality of care theyre providing
  your patients.

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• Compliance
• As mentioned earlier, staying compliant with all
  the latest regulations and coding guidelines in
  California can be complicated because of how
  regularly they are updated, so working with PMN
  means your practice is always going to remain on
  the right side of the law.
• So, if youd like to learn more about the
  difference PMN can make in the more
  administrative side of running your medical
  practice, we recommend getting in touch by
  calling [phone] or even booking a
  face-to-face appointment at their office in
  Laguna Hills, Orange County, California!