For those not familiar, utilization review is a case management function performed in hospitals that serves to validate medical necessity for in-patient hospital stays. Many insurance companies require hospitals to communicate medical necessity for each patient every day during a patient's hospital stay. Based on the clinical indications and accepted best medical practices, the insurance will either authorize the patient's day in the hospital or deny it. Accordingly, case management and utilization review are very important to hospital's revenue.
Clinical documentation improvement is a program some hospitals employ to improve physician documentation for the purpose of coding accuracy and appropriate DRG assignment. Since payers, like Medicare, pay for services based on DRG, the more accurate the coding, the more accurate the payment.
To accomplish this goal, clinical documentation improvement specialists (usually nurses or coders) are specially trained to review medical records and identify clinical indications or "hints" that the initial DRG assignment may be inappropriate. This is very important from both a financial and a compliance perspective.
For example, if a patient comes to the hospital with chest pain, the DRG assigned is for chest pain. But, when a clinical documentation specialist (CDS) reviews the record, they may find clinical evidence that the patient had a heart attack and therefore a heart attack DRG is more appropriate. The CDS can then work with the physician to help them learn to document better so the right DRG is coded and billed. In many cases, that improvement in documentation and coding has a very positive financial impact.
Check out the article here: http://www.hpnonline.com/inside/2012-06/1206-CBS.html
Check out the article here: http://www.hpnonline.com/inside/2012-06/1206-CBS.html
