Clinical Documentation Improvement

Friday, March 27, 2009 at 10:43:20 AM

Wellspring Consulting is providing education for the Medical Staff on clinical documentation improvement. The purpose is to help physicians bridge the gap between coding terms and clinical terms in order to reflect the most appropriate severity of illness and co-morbid conditions. Information must be included in the doctors’ notes in order to be considered relevant for coding. Using “probable” or “possible” or “rule out” is permitted when the diagnosis isn’t clear, but medical necessity needs to be shown. This can also affect length of stay and reimbursement for the hospital and the physician.
Education is taking place currently with groups of doctors having the most impact on in-patient documentation, i.e. hospitalists, emergency room, and intensivists.
The most important thing that a physician can do is to document in the chart answers to questions posted by the case manager. Please contact Trish Jewson for more information about the educational sessions at 763-6202.

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