Background: Accurate coding is paramount to hospital revenue generation and is often supported by a clinical documentation integrity (CDI) team made up of registered nurses and non-clinical coding personnel. Physician-led coding initiatives have demonstrated improvement in case-mix index and clinical documentation. We hypothesized that physician integration into CDI would result in a more robust improvement [...]

Background: Malnutrition, defined as deficiencies or excesses in nutrient intake, is associated with worse short and long-term outcomes compared to similar people without the diagnosis. The ASPEN or GLIM criteria are used to diagnose malnutrition, but these criteria are somewhat vague and measurement standards are typically not objective. The Inpatient Prospective Payment System considers severe [...]

Background: Accurate clinical documentation is necessary for many aspects of modern health care, including excellent communication, quality metrics reporting, and legal documentation. However, since coding rules and terminology differ from common clinical language, there is a risk that the clinical reality will get lost in translation. This is where clinical documentation improvement (CDI) programs come [...]

Background: Many hospitalized adults arrive with pre-existing malnutrition, which is associated with high risk of adverse outcomes. As such, malnutrition is a common variable in cost and quality risk adjustment models based on hospital discharge diagnosis codes. Hospital dietitians assess patients for malnutrition and generally document the details of their evaluations. However, coding professionals cannot [...]

Background: Early sepsis recognition and treatment can save lives. The Centers for Medicare & Medicaid Services defines appropriate treatment using the Severe Sepsis/Septic Shock Early Management Bundle (SEP-1) components. To help improve sepsis identification, documentation, and organizational compliance with SEP-1, our hospital implemented a “best-practice alert” (BPA) comprised of Epic’s “sepsis score,” but the rates [...]

Background: Malnutrition is a significant indicator for illness severity and expected mortality. Prior to any process improvement interventions in 2014, only 4.7% of UNMH inpatients were diagnosed with malnutrition at discharge, much lower than the published national inpatient prevalence of 20-50%. Given the relatively high level of poverty in NM, we believe these lower rates [...]

Background: On October 1, 2007, Medicare changed their payment structure from Diagnosis Related Group (DRG) to Medicare Severity-Diagnosis Related Group (MS-DRG) based reimbursement. This led institutions to prioritize clinical documentation improvement (CDI) programs in an attempt to align healthcare resources with patient complexity. Complete documentation has other benefits to a healthcare system as well. These [...]

Background: On January 1st, 2023, the AMA released updated CPT E&M codes and guidelines. While there were welcome aspects to these changes – including removing need for an extensive physical exam and making it easier to capture prolonged service time – healthcare systems were left grappling with a need to quickly respond to these complex [...]

Background: Medical training often lacks formal education on accurate documentation for billing and coding. Studies show residents are aware of their lack of knowledge and have a desire for more training[1-4]. Consequently, attending physicians lack confidence in billing and coding and also desire further education [5]. However, there is a paucity of studies on effective [...]

Background: Hospital Medicine continues to be a rapidly evolving field. Within our own institution, 15-20% of our graduates in the Internal Medicine Residency Program in recent years have pursued careers in hospital medicine. Although hospitalists and residency program leaders recognize the importance of clinical documentation and accurate coding, curricula to teach the basics are lacking [...]