clinical documentation update cardiology service line l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Clinical Documentation Update Cardiology Service Line PowerPoint Presentation
Download Presentation
Clinical Documentation Update Cardiology Service Line

Loading in 2 Seconds...

play fullscreen
1 / 11

Clinical Documentation Update Cardiology Service Line - PowerPoint PPT Presentation


  • 165 Views
  • Uploaded on

Clinical Documentation Update Cardiology Service Line. 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.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Clinical Documentation Update Cardiology Service Line' - symona


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide2

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
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

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 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
Clinical Documentation Update

Questions about this presentation? Please contact:

  • Thenia Nesbeth-Blades,RN,MSN

Documentation Improvement Specialist

thn9003@nyp.org

(212) 305-0337