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You are here > Home > Reading Lists > Finance & Accounting > Guide to Outpatient Clinical Documentation Improvement

Guide to Outpatient Clinical Documentation Improvement: The First Step in Revenue Cycle Management
Beverly Pybus, CPMSM

Hardcover: 206 pages + bonus CD-ROM
ISBN 1578393043
HCPro
January 2003
Price $149.00

 

This book and CD-ROM set brings you the long-sought solutions you need to improve your hospital's outpatient documentation. 

Improving your documentation can help ensure full compliance and appropriate reimbursement.

Accurate and timely outpatient clinical documentation is important for a number of reasons - especially to be in compliance with government regulations and to ensure appropriate reimbursement. Outpatient encounters are also growing in numbers, and, in many cases, surpass inpatient care as most hospitals' main source of revenue. Guide to Outpatient Clinical Documentation Improvement focuses on facility-based outpatient venues and the impact that clinical documentation can have on reimbursement, regulatory compliance, accreditation, and, ultimately, patient care.

The documentation lessons providers learn for the inpatient setting do not transfer to the outpatient environment. These lessons don't apply for the following reasons, each of them characteristics of outpatient care:

  • There are high numbers of encounters
  • Encounters begin and end quickly
  • Patients often make multiple visits in one day
  • Documentation is limited
  • There are different coding guidelines for outpatient services
  • There are multiple coding systems
  • Billing needs are different for outpatient claims
  • Increased use of automation
  • "Trigger events" that start the documentation process
  • Documentation from multiple physicians and clinicians
This guide addresses four types of outpatient, facility-based services: emergency department (ED) visits; diagnostic testing (including laboratory, radiology, and other types of tests performed for diagnostic purposes), ambulatory surgery unit (ASU) visits; and observation. These four types of encounters account for over 90% of the facility-based outpatient visits that health care organizations provide.

Ms. Russo outlines the basic concepts of clinical documentation improvement (CDI) as they apply to the outpatient setting, and covers regulatory, licensure and legal implications for outpatient documentation. She lays the groundwork to help readers implement an outpatient CDI program, and provides analysis and tips to help you determine the program's impact and value to your facility. She closes with a discussion of CDI methods and implications in each of the four outpatient settings in focus: the ED, diagnostic testing, ASU, and observation. Ms. Russo, co-founder and CEO of HP3, Inc., has designed documentation improvement programs for acute care hospitals and documentation training programs for physicians and clinicians throughout the health care continuum.

Hardcover: 206 pages + bonus CD-ROM
ISBN 1578393043
HCPro
January 2003
Price $149.00

 

This book and CD-ROM set brings you the long-sought solutions you need to improve your hospital's outpatient documentation. 

With more than 17 years of experience, HCPro, Inc. is a leading provider of integrated information, education, training, and consulting products and services in the vital areas of healthcare regulation and compliance. The company's mission is to meet the specialized informational, advisory, and educational needs of the healthcare industry. As an acknowledged industry authority in healthcare regulation and compliance, HCPro focuses on providing its clients assistance and expertise in the areas of accreditation, medical staff affairs, credentialing, privileging, medical record management, regulatory compliance, nursing, quality/patient safety, infection control, and workplace safety.

(information from the publisher)

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