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Clinical Documentation Improvement: Implementation and ...

8/19/20151 Clinical Documentation improvement : Implementation and BenefitsThe Problem: There are minimal areas to improve revenue within the health care system that are economically feasible for rural and community hospitals Cost Cutting is the focus by: Increased fraud enforcement Down-grading for failure to document Severity of Illness or Medical Necessity Recovery of paid claims with retrospective denials and prospective denials (RAC) (MAC) Payment is linked to quality measures or outcomes Value Based Purchasing InitiativesANDIf it is not documented by a physician, a code cannot be assigned and it cannot be billed2 TruBridge, Proprietary and Confidential28/19/20152 Denials:Title XVIII of the Social Security Act; 1862(a)(1)(A).. no payment may be made under Part A or part B for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Clinical documentation improvement • The process to ensure that the information documented (by the provider) is accurate, complete, specific, timely and meets coding

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