E/M related to CDI

cari.merlina@uchealth.org

Our CFO has tasked us with inquiring physicians if CDI (6 months up and running..) has impacted their E/M levels. This is a topic I have know nothing about! We are looking for greater physician buy-in and hoping we can "sell" ourselves by pointing out how the increased acuity due to CDI queries increases their revenue. Thanks for any info.

Best Regards,

Cari Merlina RN, BSN
Clinical Documentation Improvement Specialist
Revenue Cycle
Yampa Valley Medical Center
1024 Central Park Dr
Steamboat Springs, CO 80487
p.970.871.2425
f.970.875.2796
Cari.merlina@yvmc.org

kwilliams@halifaxrmc.org

I do not know how to measure this, but when ccs and MCCs are captured it shows the severity of illness and risk of mortality for the patient. There are 3 components that determine the appropriate billing level for e/m visit: history, exam and medical decision making. Eac of these has various levels of complexity and sub-components. The proper level of complexity is determined by the presence or absence of documentation for four sub-elements: chief complaint, history of present illness, review of systems, and past, family, and/or social history. Thoroughly documenting what was doen for the patient and why is crucial to support the levels of billing.


Kim Williams, RN
Clinical Documentation Specialist
Halifax Regional
Revenue Management Department
kwilliams@halifaxrmc.org
(252) 535-8154
(252) 535-8937 fax

kwilliams@halifaxrmc.org

Thank goodness they don't bill on my spelling.