Clinical Documentation Improvement

Clinical Documentation Improvement

Unprecedented Healthcare Challenges

  • Inadequate physician/clinician education?
  • Disruption to physician workflow and inability to achieve physician buy-in?
  • Inadequate CDI staffing resources?
About 500 million patient record entries are created that contain poor quality clinical documentation*

Atos ensures that clinical documentation is accurate, complete and compliant. Atos' CDI program ensures Quality Outcomes and Revenue Integrity through coordination, collaboration and communication that reflects the care and service provided.

Atos' clinical documentation service line is comprised of registered nurses with strong clinical background. All team members are ACDIS certified Clinical Documentation Specialists (CCDS). Electronic access data base and query templates support and enhance the CDI process and provide reports on CDI productivity and key program metrics.

Atos places Quality high on the priority list. CDI best practice performance metrics/ benchmarks are tracked/reported monthly. Ongoing verification process and quarterly audits validate CDS’s appropriate identification of documentation improvement opportunities, as well as, validates that the query process is compliant with industry and regulatory guidelines.

CDI Program Management
Atos' comprehensive CDI approach includes assessment, implementation, management, and regular audits. A collaborative model with a highly experienced team consisting of certified clinical documentation specialist nurses who are focused on delivering a best-fit solution that includes
  • Managing the complete CDI program, instituting best practices and dashboards to measure success and all operations and functions related to, clinical documentation, including concurrent CDI record reviews, queries, physician education and metric dashboards;
  • Provide CDI-specific communications to executive management to review the CDI Services;
  • Serve as CDI subject matter experts and resource for issues relating to CDI best practices; 
  • Develop/Maintain a CDI workflow process;
  • Develop ongoing maintenance and periodic revision of policies and procedures relating to CDI services;
  • Continuing education and communication plan for CDS staff/physicians;
  • Engage CDI team in physician education via newsletters, tip cards, presentations;
  • Rolling audits to identify educational opportunities/trends, and development of physician and CDS relationships to foster quality and accurate documentation;
  • Provide compliant query templates inclusive of ICD-10 language/expectations.

CDI Audit Services
Inpatient CDI Audits
Atos offers a thorough assessment of current documentation which pinpoints opportunity for queries, improved documentation specificity, quality and ensures compliance.

The reviews will also provide:
  • Potential changes in principal diagnosis or procedural coding
  • Additional findings that capture comorbid conditions
  • Impact to Severity of Illness (SOI) and Risk of Mortality (ROM)
  • Query Compliance:
    • Identify for compliance; verify questions are open ended and non-leading to minimize risk, and identify if ICD-10 ready
  • Comprehensive ICD-10 audit finding:
    • Identify diagnosis, physicians, and service lines that will require improved documentation specificity based on the current ICD-10 guidelines
  • Identify opportunity for further physician education on appropriate documentation opportunities
CDI Program Assessment
Atos performs onsite CDI assessments to evaluate the “Foundations” of CDI Programs and provides feedback, recommendations and process improvement strategies

  • Defined Goal & Departmental Structure
  • Staffing, CDI Roles & Productivity
  • Efficient Process Workflow
  • Strong Relationships (e.g. Physicians, Coding, Case Management, Utilization Review)
  • Measurement & Accountability
CDI ICD-10 Physician Education Offerings
Physician Service Line Education:
Customers can choose from a list specific service line education offerings.

Key learning objectives include:
  • Develop understanding of the role documentation plays in determining patient severity of illness (SOI) and risk of mortality(ROM)
  • Examine the impact of SOI/ROM on physician quality scores
  • Understand definition/terminology changes in ICD-10-CM and ICD-10-PCS
  • Understand the concepts of linking conditions and manifestations and specificity requirements for more accurate depiction of patient status
Individualized Physician Education:
Atos' CDI team will perform a detailed chart audit to drill down and examine select physician’s documentation records in an effort to gain insights into the physician’s documentation tendencies and improvement opportunities.

Key Concepts Include:
  • Impact on severity of illness and risk of mortality and why documentation matters
  • Review personal physician chart documentation examples
  • Brief overview of the impact of documentation/ICD-10 to their service line
  • Key educational concepts/training identified from the chart audit to improve their documentation habits and help drive quality scores

Healthcare CDI Services

(914) 881-3000