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Heartland ACDIS & Clinical Documentation Management

Healthcare has moved beyond the decade of managed care to the decade of public profiling of results, objective quality outcomes, and pay-for-performance and government audits. Very minor changes in documentation may alter your financial outcomes and assist in obtaining credit for the severity of illness of the patients whom you treat.

SoutheastHEALTH’s Clinical Documentation Management Program began in 2010 and is designed to ensure that physicians’ clinical documentation provides sufficient specificity and agreement with compliant terminology to ensure physician and SoutheastHEALTH receive credit for the severity of illness of patients treated and for the service provided. To meet this goal Clinical Documentation Specialist Registered Nurses (CDI’s) receive in-depth training on coding guidelines, specificity reporting, risk of mortality reporting and current medical terminology requirements by Center for Medicare & Medicaid Services for medical necessity. This training allows the CDIs to educate Physician and Allied Health Partners and prompt concurrent documentation regarding medical necessity reporting on In-patient claims.

Meeting the increasing demand for knowledge regarding quality clinical documentation requires support from fellow CDIs. In 2012, SoutheastHEALTH began building their local chapter through the national chapter of the Association for Clinical Documentation Improvement Specialist. The Heartland ACDIS chapter includes partners from the entire southeast region of Missouri.

Our goal is to provide quality educational resources to all CDIs, Coders and clinicians regarding severity of illness, risk of mortality, present on admission indicators, core measure reporting and appropriate profiling of physician care through education of ourselves and the healthcare community we serve.

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