AI-powered Clinical Documentation Improvement is Revolutionizing the Physician Documentation Process, Reinforcing Compliant Coding and Driving Increased Reimbursement
In this age of AI and smart health systems, clinical data is of paramount importance to healthcare providers. It is not only crucial for medical decision-making and continuum of care, but also essential to support precise level of coding, improve compliance, and mitigate claims denial. Physicians often find recording clinical data arduous due to high workload, reimbursement policy updates, and seemingly arbitrary insurer decisions. Addition of new acronyms to healthcare vocabulary and unfamiliarity of how documentation and coding contribute to reimbursement further complicate matters. Consequently, suboptimal documentation often leads to revenue loss through under-coding and claims denial. Employing the AI-powered clinical documentation improvement (CDI) led coding solution from Omega Healthcare empowers physicians with chart-specific CDI feedback. The fully integrated insights improve first pass payment and ensure more wins on appeal when claims are denied.
Empowering Coding with Focus on Quality Documentation
Coders often fail to code a patient encounter accurately when pertinent data is missing. Typically, in evaluation and management (E&M) and critical care settings, compliant coding entails accurately identifying multiple elements. Physicians must meticulously capture history, ROS, exam, medical decision-making, diagnostic/therapeutic interventions, plan of care, findings of lab tests/imaging/ECG, etc. Similarly, documenting the complexity and intensity of care furnished during the patient encounter is crucial to capture professional fee codes. Empowering coders with accurate physician documentation enables precise level of coding (level 3 versus level 5, for example), justification for risk adjusted coding, and maximizes work relative value units (wRVUs). Ultimately, quality documentation helps improve capturing compliant revenue.
Revolutionizing Clinical Documentation Improvement with AI
It is more important now than ever for practices to scrutinize the current documentation process and identify opportunities for improvement. Adopting an analytics-led approach, Omega Healthcare leverages AI to ensure document integrity and compliance for better reimbursements and margins.
Omega Healthcare’s Clinical Documentation Improvement Specialists leverage the proprietary clinical cognitive engine to review charts and provide near real-time actionable CDI feedback to physicians. Working directly with physicians, the CDI Specialists assist them with capturing all relevant elements of a patient encounter to commensurate with latest reimbursement guidelines and compliant coding practices. The AI-powered Clinical Documentation Improvement solution leverages advanced machine learning (ML) and natural language processing (NLP) platforms to review charts and provide near real-time prospective CDI feedback within the EHR. The continuous feedback enhances compliance, improves wRVUs, and increases reimbursement in all types of clinical care settings. The AI-powered CDI solution also provides physicians and administrators with chart-specific performance reporting on compliance, customized education materials, and comparative dashboards on deficiency levels retrospectively.
Wrapping Up the Discussion:
Physician documents serve an array of purposes, in addition to protecting patient, provider, and payer interests. Physicians need to ensure clinical documents are compliant with regulatory and reporting standards. The documents must match the level of granularity required to triumph in appeals of claims denials. Unfortunately, many physicians lack the time or familiarity to make sure their documentation is up to standards. AI-powered Clinical Documentation Improvement led coding from Omega Healthcare empowers physicians to reinforce the quality and content of clinical documents. The optimized documents ensure precise level of coding, improving compliance and reimbursement, while easing administrative burden and elevating patient care.
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