Clinical Documentation Improvement

MEHIM’s CDI tools and education positively impact the quality and quantity of physician documentation in the medical record at the point of service. This results in comprehensive physician documentation and ensures that diagnoses reflect the patient's severity of illness, as well as intensity of service for patient encounters. The end result is a Case Mix Index (CMI) that accurately reflects the acuity of the patients that your hospital treats. The MEHIM CDI Team simultaneously implements the program as we train your documentation specialist(s) how to perform the concurrent review process of the medical record. The documentation specialist learns key elements and technique for chart review.

MEHIM initially takes the roll of physician liaison while simultaneously training your designated team member to be the permanent replacement. Proficient communication between the clinical documentation specialists and the physicians is the key to ensuring the program success. The MEHIM Documentation Team uses data from the concurrent documentation review process to show reimbursement variance based on pre-query and post-query tracking.

This ensures that the billed diagnoses and DRG assignment are correct. Our program also verifies:

  • Whether or not diagnoses were present on admission.
  • That the principal diagnosis was truly the reason for admission.
  • That the patient received treatment and/or evaluation for the conditions reported as secondary diagnoses during their hospital stay.

The MEHIM CDI Program trains your staff how to effectively and efficiently communicate with physicians and all other relevant patient care givers that have an impact on code and DRG assignment. This method has been proven to enhance the documentation quality.

It will accurately show management the case mix, and revenue impact that without the concurrent review would have been lost. We assist your staff on how to create and execute coding quality monitors in accordance with your hospital’s compliance plan. We utilize specific software as well as other electronic methods for tracking the data. It provides reports and spreadsheets with the DRG weight variances identified from the physician query responses. It also tracks physician non- compliance with query requests and other aspects of the CDI program.

Elements of our CDI Program:

  • Review the medical record for comprehensive and accurate documentation.
  • Concurrent querying of physicians to thoroughly document principal and secondary diagnoses for the patient's admitting signs and symptoms as well as chronic conditions to support the medical treatment delivered in accordance with AHIMA guidelines and the UHDDS.
    • Generate Standards of Conduct.
    • Strive to get the most resource intensive DRGs by applicable grouper.
    • Ascertain how documentation impacts the DRG.
    • Enforce communication between coders, nurse managers, physicians, and other care givers through a continuous internal educational process.
    • Create documentation tools and monitoring forms.
    • Measure and analyze the progress, quality and financial impact of the program.
    • Discover the importance of working simultaneously and harmoniously with care givers as well as other ancillary departments that are vital to a comprehensive documentation process.

The MEHIM Documentation Improvement Program combines clinical and coding knowledge to ensure that clinical documentation reflects the appropriate severity of illness adhering to all compliance and coding regulations. This will assist in accurate POA assignment as well as MS-DRG assignment. Our program will provide your hospital with an increase in Case Mix Index (CMI) and appropriate reimbursement.

The MEHIM CDI Team will come to your hospital and assess documentation improvement opportunities, implement the program, educate and train your staff, and help maintain the program on an on-going basis. Contact us today to set up an on-site evaluation.

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