Health Information Management

Q&A: How many people should be involved in reviewing a medical record?

CDI Strategies, April 14, 2016

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Q: How many people should be involved in reviewing a medical record?

A:
With the current focus on greater efficiency, hospitals should consider the number of people reviewing precisely the same documentation but for different purposes. Utilization reviewers are screening documents for evidence of medical necessity; clinical documentation improvement (CDI) specialists are screening the documents to identify opportunities for the physician to consider greater specificity and clarification; and medical record coders are reviewing the same series of documents to assign accurate codes for the claim forms and to comply with the broad array of regulatory reporting requirements.

There is some evidence that the introduction of user-friendly CDI applications has prompted the integration of the CDI and UR specialist roles; most recently in the emergency department. In the meantime, CDI programs are becoming more sophisticated as newer applications provide physician access to CDI queries via smartphones and tablets. By streamlining the query and response process, coders will be able to shorten the time between review and dropping a clean bill.

Similarly, the introduction of computer-assisted coding (CAC) applications adds a new. Some CAC applications can highlight key clinical terms in selected documents for easy recognition by reviewers and coders. CAC applications can auto-assign an ICD-9 or ICD-10 code, which brings the value of concurrent coding into question. Developing a method for efficiently integrating a portion or all three primary review activities—UR, CDI, and concurrent coding—is a struggle for many in the healthcare industry, and there is no best practice approach rather facilities must examine each record review process and identify opportunities of collaboration, area of overlap, and develop effective policies to effectively manage the process.
 

Editor’s Note: This article is an excerpt from the book The Hospital Guide to Contemporary Utilization Review



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