Denial Management-Moving Upstream in the Revenue Cycle
Glenn Krauss
Creator and Founder of Core- CDI; Co-Founder of Top Gun Audit School------ Physician Advocate & Champion-Partnering with Physicians to Help Achieve Physician Documentation Excellence----While Working Smarter-Not Harder
CDI plays an integral role in the revenue cycle of hospitals, working in close tandem with coding to assure the record speaks for itself to facilitate accurate compliant clinical coding that stands the test of time from outside regulatory scrutiny. We can be an effective catalyst in working in tandem with our patient financial services/denials and appeals department to transform the role to one incorporating an embracing mindset and transformation to "denials avoidance." Take a moment to read this article on the merits of moving upstream in the revenue cycle to avoid costly repetitive self inflicted denials in the first place. Stay tuned for an outline on how CDI can be a driving force in alleviating the epidemic of continual repetitive denials through CQI in our present processes.
https://blog.zirmed.com/denial-management-moving-upstream-in-the-revenue-cycle
Creator and Founder of Core- CDI; Co-Founder of Top Gun Audit School------ Physician Advocate & Champion-Partnering with Physicians to Help Achieve Physician Documentation Excellence----While Working Smarter-Not Harder
8 年Mary Ellen, this lack of clarity and explicitness in the reporting of the clinical information and clinical facts of the case contribute to an ever increasing number of unnecessary medical necessity denials, clinical validation denials and DRG downcodes. In some respects, current CDI processes are counter intuitive to stated goals and objectives of the revenue cycle.
Creator and Founder of Core- CDI; Co-Founder of Top Gun Audit School------ Physician Advocate & Champion-Partnering with Physicians to Help Achieve Physician Documentation Excellence----While Working Smarter-Not Harder
8 年Thanks everyone for their comments. Sandy I agree that while it is virtually impossible to to incorporate every payor nuance and variance in the CDI and coding process, there is so much more CDI can accomplish in regards to the documentation improvement process aside from capturing CCs and MCCs. First and foremost is an accurate recording and reflection of the clinical information and clinical facts of the case. CDI does not in the last bit focus upon and promote the recording of these essential elements in the communication of patient care; the main focus is upon securing documentation that increases reimbursement, low hanging fruit that is easily disputed and discounted by third party payers given the lack of physician clinical judgment, medical decision making and thought processes in support of the diagnosis. In fact I am convinced that CDI unequivocally contribute to unnecessary, avoidable self inflicted denials by the recording of diagnosis naked supporting clinical information in the chart to support diagnosis. Witness clinical validation denials attributable to diagnosis such as sepsis, acute respiratory failure, acute renal failure, acute tubular necrosis, malnutrition, etc. To better align with the revenue cycle, CDI as a profession must change the current framework that we operate in. Otherwise, we will be perpetuating the denials process.
Happily Retired Health Information/Clinical Revenue Cycle Leader
8 年Denials management, or avoidance, is complicated. While CDI and coding play a critical role, it is impossible to incorporate every payor nuance and variance in the CDI and coding process. And, like the practice of medicine, CDI and coding are a little bit science and a little bit art. Believe it or not, A+B can = D.
Retired consultant , educator and professional speaker for hospital case mgmt practice, utilization review, and care coordination across the Continuum. Recent recipient of CMSA's prestigious Lifetime Achievement Award.
8 年Glenn....you know that I abhor the term denials 'management' - we don't manage falls or medical errors - we try to prevent them. ditto denials. But, and its a big one, to prevent denials in the first place we must know root cause and that means data from the business office jon first pass 835s. Which is like trying to get into Fort Knox !