Although the majority of emergency department (ED) visits are outpatient, approximately 35 percent of hospitalizations originate in the ED. Many former ED patients receiving observation services convert to inpatient admission as well. The emergency department is, therefore, benefited by both inpatient and outpatient clinical documentation integrity (CDI)attention.
There are unique challenges to the practice of emergency medicine which translate into opportunities and challenges for CDI professionals. The providers work in fast-paced shifts, juggle multiple patients simultaneously, may be difficult to meet with in groups, may not be employed by the hospital, and are not judged by typical inpatient or outpatient quality metrics. Conditions in the ED may rapidly improve and the only place to capture a legitimate diagnosis may be in the ED. Conditions may also be unclear and the optimal diagnosis may be symptoms with an uncertain diagnosis, which is foreign to providers.
All conditions in the ED are present on admission, and if they aren't documented, there may be quality repercussions. One of the biggest challenges is demonstrating medical necessity to justify the patient status; this is the traditional purview of the case manager, but CDI can be instrumental in assisting the provider to depict the patient as sick and complex as they are.
This webcast will review the challenges and give the attendee tips and tools to facilitate provider education regarding documentation in the emergency department.
Why This is Relevant:
The patient encounter starts in the ED, and it should be accurate from the beginning. If you teach one emergency physician to document one MCC that wouldn't have been captured or to avoid a single HAC, you've paid for your whole department to participate.
Take this brief quiz to see if you and your team could benefit from this webcast:
- Should we query emergency physicians or only attending physicians?
- How can I convince the emergency physicians to document conditions which may be significant, but they don't think they need to include them on their impression list?
- Do I need to know MCG or Interqual criteria to help the provider document medical necessity in the ED?
- Which conditions do you think are the biggest bang for your buck to teach the emergency providers?
From this exclusive ICD10monitor webcast, led by Erica Remer, MD. you will…
- Learn how to increase the number of ED diagnoses per patient;
- Discover how to facilitate the use of uncertain diagnoses;
- Learn how to capture significant risk-adjusting diagnoses present on admission;
- Understand how to support medical necessity for status determination; and
- Learn how to improve the accuracy of mortality and other quality metrics.