Documentation Improvement | Compliance Audits | ICD-10 Education & Coding

Ease of implementation and use

• Installed within 30 days of signed contract
• One week to train CDIS team on the software
• YPRO can (when available) supply a server preloaded with Doc-U-Aide
• Minimal facility IT intervention

Flexibility/Productivity

• Ability to quickly modify a pre-formatted question to meet special situations
• Additional reporting options upon request
• CDIS and coding staff both can utilize Doc-U-Aide
• Designed to be utilized in a single facility or multi-facility to provide

      flexibility to meet your future needs

•  Your CDIS team or coding staff can add specific comments into the Doc-U-Aide system on patients reviewed as a way of providing additional specific information that can be useful to a physician or for other needs
• Built in ticker system to allow CDIS staff to post reminders by date for a patient – check H & P, check X test result, and more

Issuing a Clarification Request or Query can be completed in seconds

• Doc-U-Aide interfaces with your hospital system for patient demographic information saving CDIS/coder time
• Pre-formatted Clarification Requests or Queries to eliminate the leading questions
• Maximizes CDIS and Coder productivity
• Pre-formatted question that can accept clinical indicators i.e. lab results
• Additional education information is provided with additional wording for alternative situations
• Structured so that it documents history of communication with physician for a given patient
• Structured to prevent asking a physician the same question twice
• Doc-U-Aide tracks all clarification requests/Query status as pending, approved, declined, or no response

Compliance

• Includes help for justification and admission orders- CMS auditors are increasingly focusing on justification and admissions orders (medical necessity) -  Doc-U- Aide’s system facilitates the gathering of the required justifications and tracks corrected admission orders
• Doc-U-Aide database saves the actual wording for each clarification request or query which can be used for quality monitoring and compliance
• The Doc-U-Aide database is updated every year to meet the documentation/coding changes within the IPPS System

Enhance Physician Buy-in

• Prevents duplicate clarification requests/queries
• Doc-U-Aide includes physician E&M questions thereby helping the physician to understand how improving the specificity of their clinical documentation will impact their E&M
• For your employed physicians, Doc-U-Aide will help demonstrate how by improving their level of specificity for clinical documentation they will help themselves as well as the hospital

 

 

 

Management/Department Reporting

• Track CDIS productivity
• Track coding queries
• Track physician interaction
• Document recurring issues with individual physicians that present opportunities to provide specific education/information
• Produce a specific ROI for any time frame – document actual impact of CDIS program (more accurate impact measurement that just this months CMI)

The following is a brief outline of a suggested approach for your hospital:

• YPRO conduct a Clinical Documentation Assessment Review

• Serves as the base line for the project to measure improvement from
• Identifies specific high priority areas for your CDIS staff to focus on
• Meet with CDIS and Coding staff to discuss issues identified
• Provide written report on results

• Doc-U-Aide Installation (normally within 30 days of signed contract)

• Test patient demographics interface
• If your IT staff is heavily committed YPRO has servers with Doc-U-Aide preloaded that can be shipped to your hospital saving time
• IT staff will only need to rack mount the server and configure access along with the patient demographic interface

• Doc-U-Aide class room raining – normally one week

• How to use the software

• YRPO CDIS trainers working one-on-one on the floor with your staff – normally 3-4 weeks

• Maximize staff productivity
• Provide CDIS training to staff new to CDIS and existing staff
• Clinical Indicators
• CC/MCC issues
• Importance of complete documentation not just a diagnosis
• Help tie physician E&M to inpatient documentation
• Discuss up coming issues with ICD-10 transition (impact on documentation)
• Help with job descriptions and applicant interviews if needed

YPRO also recommends the following on-going services:

• Perform quarterly Clinical Documentation Assessment Reviews
• Show improvement in clinical documentation as a result of the CDIS project
• Refine high priority areas for CDIS staff to focus on
• Meet with CDIS and Coding Staff to discuss issues identified
• Provide written report on results
• YPRO CDIS staff can provide support should you experience turnover or sick leave to prevent any impact on CMI or quality ratings
• YPRO has developed Web based ICD-10 training/education
• Advise all CDIS and coding staff take the full course
• The training is important for your physicians as well
• Everyone who currently uses ICD-9 codes will also need some of the education modules (YPRO has defined which modules for the different staff)

 

 

If you are interested in learning more about this inexpensive yet effective CDI tool please contact a representative at 800-726-3320.