The Physician Advisor's Guide to Clinical Documentation Integrity, Third Edition

The Physician Advisor's Guide to Clinical Documentation Integrity, Third Edition

Physician advisors are no longer just needed for case management and utilization review. Increasingly, they serve as liaisons between clinical documentation integrity (CDI) and their fellow providers. Physician advisors to CDI bridge the gap between provider documentation and CDI and coding efforts, communicating with providers to ensure complete capture of the patient’s severity as well as accurate coding, reimbursement, and quality reporting.

Revised to streamline and update information, The Physician Advisor’s Guide to Clinical Documentation Integrity, Third Edition:

• Outlines the impact of CDI efforts on accurate reporting of severity of illness and quality metrics
• Offers an overview of core CDI concepts, coding guidance, and reimbursement systems
• Provides strategies for engaging the medical staff with CDI and coding initiatives
• Highlights noteworthy documentation improvement areas by body system
• Describes the key tenets of compliant querying

Each chapter focuses on the critical elements that physician advisors must understand, equipping them for success in their endeavors.

About the Authors

Trey La Charité, MD, FACP, SFHM, CCS, CCDS, is the medical director for clinical documentation, coding, and utilization integrity at the University of Tennessee Medical Center. He has previously served as the medical director for clinical integration for both the University of Tennessee Medical Center and the University Physicians’ Association, creating and implementing their combined outpatient clinical documentation integrity (CDI) initiative for their primary care network. He is a clinical associate professor in the Department of Internal Medicine where he currently serves as a teaching attending and the curriculum director for the internal medicine residency program’s hospitalist rotation. He is board certified in internal medicine and has been a practicing hospitalist since completion of his residency in 2002. He is currently serving his second term on the Association for Clinical Documentation Integrity Specialists (ACDIS) Advisory Board and is a regular presenter at the annual ACDIS annual conference and ACDIS Physician Advisor Forum. La Charité also has responsibilities in case management, denials management, medical records, compliance, performance improvement, and quality.

Nicole Fox, MD, MPH, FACS, is an experienced physician executive at Cooper University Health Care, the leading academic health system and only Level 1 trauma center in South Jersey. She is board certified in general surgery and surgical critical care. Fox graduated from Franklin & Marshall College. She received her medical degree from Rutgers New Jersey Medical School along with a master’s in public health/health administration from the Rutgers School of Public Health. Fox serves in dual roles at Cooper as a trauma surgeon/surgical intensivist as well as the associate chief medical officer for the health system. She currently serves as a professor of surgery and the trauma medical director for the pediatric trauma center. In addition, she has direct oversight of and responsibility for multiple programs within the health system including CDI, utilization review, patient experience, physician peer support, and the inpatient unit medical director program.

Deepa Velayadikot, MD, SFHM, CHCQM-PHYADV, is the medical director of care coordination and regional medical director, hospital medicine for Cooper University Health Care, which is a leading academic health system and only Level 1 trauma center in South Jersey. She is board certified in internal medicine and is a hospitalist physician and physician advisor. She oversees the Cooper Physician Advisor program that she developed, consolidated, and expanded to multiple hospital systems. She is also an assistant professor of clinical medicine at Cooper Medical School of Rowan University and director of educational programs including the care coordination clerkship and utilization management and observation services elective.