The Role of an Advanced CDI Program in a Clinical Validation Denial Appeals Process

Presented on: Wednesday, August 16, 2023 | 1:00–2:00 p.m. Eastern

Presented by: 
Joseph Anthony Christiano, MD, FACP, CCDS, CHCQM-PHYADV
Tamara A. Hicks, MHA, BSN, RN, CCS, CCDS, CCDS-O
Joy Bombay, RN, MSN, MHA, CCDS

Instead of denying certain DRGs, payers have turned to clinical validation denials for hospital stays in which one or more diagnoses are treated. In this presentation, a multidisciplinary team from Atrium Health Wake Forest Baptist, including members of its advanced CDI department, will describe the process they put into place to defend against these DRG downgrades or clinical validation denials. 

In this repeat talk from the 2023 national ACDIS conference in Chicago, join Dr. Joey Cristiano, physician advisor; Tamara Hicks, director of clinical documentation excellence (CDE); and Joy Bombay, manager of inpatient CDE, as they discuss their DRG downgrade appeals process.

At the conclusion of this program, participants will be able to:

• Describe the role of an advanced CDI program in a clinical validation denial appeals process
• Discuss how to build a clinical documentation excellence/PA/coding denials appeal team and workflow
• List key metrics for measuring performance of a denials appeal team

Agenda

• Advanced CDI programs
• Clinical indicator policies systemwide
• Physician accountability
• Concurrent HAC/PSI review
• Engagement in facility initiatives
• Clinical validation
• Outpatient CDI
• Risk adjustment
• Denial prevention and appeal support
• Quality
• Multidepartment collaboration
• Role in a clinical validation appeal process
• Multidisciplinary team
• Using a confidence scale
• Collaborating to appeal denials when appropriate
• Key diagnoses
• Sepsis
• Respiratory failure
• Malnutrition
• Acute renal failure
• Encephalopathy
• Rationale for denials
• Clinical validation
• Sequencing of diagnoses
• Root operation and approach on procedures
• Cases with only one CC or one MCC
• Preventing denials in the first place
• Building a denials appeal team and workflow
• Who needs to be on the team?
• Who are the best people for the team?
• Establishing a workflow
• Technology
• Tools
• Workflow
• Confidence scale for denials
• Key metrics
• Lead metrics
• Volume of denials reviewed
• Volume of appeal letters
• Lag metrics
• Overturns
• Revenue recovery
• Tips for building a denial review team
• Lessons learned

Who Should Listen?

• CDI directors
• CDI staff
• HIM/coding directors and managers
• Coding staff
• Revenue integrity directors and managers
• Revenue integrity staff
• Denials and appeals staff
• Quality professionals

Meet the Speakers

		Joseph Anthony Cristiano, MD, FACP, CCDS, CHCQM-PHYADV, is assistant professor of internal medicine/physician advisor at Atrium Health Wake Forest Baptist in Winston-Salem, North Carolina. He is a physician advisor for the Atrium Health Wake Forest region of the enterprise health system. He holds certifications from ACDIS (CCDS) and the American Board of Quality Assurance and Utilization Review Physicians (CHCQM-PHYADV). He created the physician advisor program focusing on clinical documentation excellence (CDE) at Atrium Health Wake Forest Baptist.
		Tamara A. Hicks, MHA, BSN, RN, CCS, CCDS, CCDS-O, is director of CDE at Atrium Health Wake Forest Baptist. She has over 39 years of experience, including over 24 years in CDI. A founding member of Wake Forest’s CDI team in 1999, she also served as a founding member of the ACDIS Advisory Board and was reelected to the board in 2016. Hicks co-wrote the original CCDS exam, serves on the ACDIS CCDS-O Certification Board, is the social media coordinator of the North Carolina ACDIS board, and was 2019 ACDIS Professional of the Year.
		Joy Bombay, RN, MSN, MHA, CCDS, is inpatient manager for CDE at Atrium Health Wake Forest Baptist. She holds a clinical/leadership position that coordinates all activities related to compliance, denials management, mortality reviews, and quality assurance as well as education with the CDE team and providers. Her CDI career started in 2014 after she spent 20 years in bedside nursing, providing care in the acute care setting as well as nursing leadership.

Continuing Education

ACDIS
This program has been approved for 1 continuing education units towards fulfilling the requirements of the Certified Clinical Documentation Specialist certification, offered as a service of the Association of Clinical Documentation Integrity Specialists (ACDIS).

Ability to claim this credits expires: 8/15/2024

AHIMA
This program has been approved for 1 continuing education unit(s) (CEUs) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting of Approved CEUs from AHIMA does not constitute endorsement of the program content or its program provider.

Ability to claim credits for this webinar expires on: 8/14/2024

ANCC
HCPro is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

1 contact hours for nurses are available for this activity.

Ability to claim this credits expires: 8/15/2024

NAHRI
This program has been approved for 1 continuing education units towards fulfilling the requirements of the Certification in Healthcare Revenue Integrity (CHRI), offered as a service of the National Association of Healthcare Revenue Integrity (NAHRI).

 Ability to claim this credits expires: 8/15/2024 

Instructions

Webinar system requirements and program materials: 
To fully benefit from the webinar experience, please note you will need a computer equipped with the following:

Browser: Microsoft Internet Explorer or Edge, Firefox, Chrome, or Safari, with JavaScript enabled 
Internet: Internet connection (high-speed connection recommended) 
Streaming: Access audio/video streaming from any browser on a computer, mobile, or tablet device

Prior to the webinar, you will receive an email with detailed system requirements, your login information, presentation slides, and other materials that you can print and distribute to all attendees at your location. 

CAN'T LISTEN LIVE? 
No problem. The On-Demand version will be available. Use it as a training tool at your convenience—whenever your new or existing staff need a refresher or need to understand a new concept. Play it once or dozens of times. A $229 value! 

PLEASE NOTE 
Participation in the webinar is just $229 per site. All materials must be retrieved from the Internet.

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