Clinical documentation is the foundation of every patient medical record. People who document in records should meet clinical documentation standards. The record supports the severity of the patient's condition, assessments and evaluations leading to diagnoses and treatment management. Without strong documentation, it becomes difficult to support the medical necessity of services provided, opening the door for additional information requests, down coding, or denial of services. Additionally, in situations where legal action has been initiated, the record will provide the support needed by the provider to justify management and billing. If the record contains vague and ambiguous language, or is missing key information, this advantage is significantly compromised, and may lead to a costly negative outcome. Coders need high quality documentation to determine coding quality and accuracy, and cannot assume a diagnosis unless documented by the provider. Every regulatory agency is placing heavier emphasis on clinical documentation. As the industry moves toward value based medicine and blended payments, rather than fee-for-service, providers must become more focused on the documentation. The advantage really is in the details.

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We spend more than half our lives at our jobs. It’s time to see our professional lives for what they are—our lives. It’s time to not just see our 9-to-5s as work but to see ourselves as part of a community of individuals striving to learn and grow. It’s time to see your job in clinical documentation integrity (CDI) as an opportunity to Flourish personally and professionally. The 2023 ACDIS National Conference takes place Monday, May 8–Thursday, May 11, 2023, at the Hyatt Regency Chicago, offering five tracks of unparalleled education over three extraordinary days that’s more than 50 opportunities to nourish your professional soul, fertilize plans for your career growth, cultivate your staff, and see your CDI program blossom.

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This course is highlighted with an introduction to the new OASIS E questions which are effective January 1, 2023. CMS has released new info on the latest questions that will affect your bottom line under PDGM. Medicare will implement Home Health Value-Based Purchasing also effective January 1, 2023 with 2019 currently set as the base year for Quality Improvements. Agencies will have their payments increase or decrease as much as 5% in 2025 based on quality improvement performance when compared to home health agencies nationally. Learn the keys to success under PDGM and understanding these important new changes for home care. This course is designed to bring you up to date and offer practical knowledge needed to adapt to changing industry demands. 

Documentation continues to be the number one risk area in home health operations regarding retaining reimbursements from Federal, State and Commercial Insurance payers and in determining STAR Ratings. Being ahead of the crowd and understanding the role YOUR documentation plays is even more critical futuristically. Defensible Home Care documentation is the key to survival with Targeted Probe and Educate (TPE) audits or any ADR’s, accurate functional scoring, star ratings and ultimate PDGM success. Learn the importance of the comprehensive assessment to support the POC and OASIS responses and be prepared for survey by adherence to the CoP’s.

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The Value-Based Payment model for medical services is gradually replacing the traditional Fee-for-Service model for payers and healthcare organizations. Clinical documentation programs are being reinvented due to the ever-changing nature of the healthcare industry. Value-based purchasing and other reimbursement issues, such as patient safety indicators, audits, and hospital-acquired complications (HAC), are dependent upon reliable, accurate, and complete documentation. Join us as we discuss the value-based CDI trends that we are seeing in the market and review practical approaches to plan and equip your CDI teams for the changes ahead.

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The importance of the patient story cannot be underestimated it can be the difference between life or death. Acknowledging that documentation errors have the potential to cause patient harm and that those errors happen far too frequently is the first step in reducing avoidable adverse events. Help bring awareness to the importance of healthcare documentation that supports patient safety and wellness. Share your story with AHDI at ahdi@ahdionline.org. Join AHDI for a special online ASK AHDI session May 18, 2022, at 12 pm CT as we celebrate Healthcare Documentation Integrity Week and all the healthcare professionals who contribute to the integrity of the medical record.

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As the list of responsibilities for today's physicians grows, reducing documentation burden and cognitive overload are a must for healthcare leaders. Join us for a fireside chat with a panel of CMIOs as we discuss the ways computer assisted physician documentation (CAPD) is boosting provider satisfaction and enabling higher quality care for the patient.

Key Learning Points:

• How artificial intelligence can support the existing documentation workflow across different care settings
• How to determine what care setting should go first based on your organization’s strategic initiatives
• What to consider in your evaluation process
• Best practices for demonstrating outcomes and return on investment

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Clinical documentation integrity (CDI) programs have proven to be highly successful at ensuring patient stories are fully documented, and reimbursement is appropriate. However, when physicians need to return to a patient record to answer retrospective queries, they often see it as administrative burden that leads to even more burnout.   

In this session, Kory Anderson, MD, and Kearstin Jorgenson from Intermountain Healthcare will discuss how they work with their teams to address this longstanding challenge with a transformational approach to CDI. You’ll learn how the patient-centric structure that underpins their physician-led CDI program keeps patient and physician well-being at the center of what they do. Don’t miss how the adoption of advanced AI brings physician and CDI workflows together and supports physicians at the point of care as they document in the EHR. Finally, you’ll learn about Intermountain Healthcare’s strategy for physician education and buy-in, and how the organization uses data to drive continuous improvement.