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A patient’s chart should stand alone as an accurate record of their illness and treatment. It is a valuable medical and legal document. A complete assessment will provide continuity of care, quality statistics, mortality/ morbidity data collection, and accurate reimbursement. 

CDI professionals review of medical charts is quite possibly their most important responsibility. It is believed they can review 16-24 charts a day, depending on the facility size. A thorough evaluation is performed looking for incomplete, conflicting, illegible documentation of diagnoses, treatments, and procedures, in addition to measuring clinical care. 

Setting a clear goal for CDI patient chart review requires knowledge of reimbursement and quality standards. CDI professionals aim to convey the patient’s story from admission to discharge by examining, reviewing, and comprehending many pieces of information from varied sources and systems. This process requires extensive clinical sharpness, critical thinking, knowledge of coding, and quality practice management skills.

One of the most significant challenges in streamlining a medical chart review process is contending with varied organizational structures and focusing on different end goals, resulting in differing review emphases. This can be challenging as it requires access to upper management and negotiating with other departments with competing interests. Communication is key. 

A patient chart review should begin 24-48 hours after admission and/or when initial assessments have been completed. A good rule to follow could be reviewing a chart when the medical history and physical are conducted, followed by initial diagnostic testing. 

The CDI specialists focus changes with each subsequent review. They follow up on physician query responses, update codes, and possibly change their diagnosis based on the documentation of the patient’s care. 

CDI review of patient charts requires time and thought, and the process itself needs to be tracked and recorded. It should be clear, detail-oriented, and thorough. If a colleague picked up the chart for a re-review, they should be able to read and understand the reviewer’s thought processes and conclusions. 

Different types of medical chart reviews exist, and professionals performing reviews must be trained and experienced. 

Chart review for determining medical necessity. The most common type is preauthorization and hospital review. Non-urgent requests must be authorized before actually taking place. Reviews performed during a hospital stay aim to determine the length of stay, whether an extension is necessary, and to determine if an appropriate level of care is being administered. Insurers may use a company that reviews medical charts, and a hospital may use a dedicated team of physicians. Hospital reviews done by physicians do not directly affect payment of services. Primarily they are used to prevent payment denial by anticipating the insurer’s conclusions. 

Chart review for legal purposes. In legal cases where medical diagnoses and treatments are involved, courts require information from an expert to determine if the medical care is appropriate, if negligence occurred, or a compromise in medical ethics. Typically these reviews are administered by a medical review team hired by the defense lawyer or plaintiff. They review all medical documentation and prepare a statement of the services provided. 

Chart review for coding and clinical documentation. Such reviews are done in conjunction with hospitalization to correct documentation before a file is claimed with the insurer. CDI reviews require professionals with a background in nursing and closely work with coders. 

Chart review for insurance underwriting. Insurance companies determine how long an individual is expected to live and what medical issues are death risks. This factor determines insurance premiums. 

In addition, medical charts can be reviewed to use data for research projects. 

Medical chart reviews play an integral part in hospitals/healthcare systems to gather data while examining ways to enhance best practices. Patience, clinical and coding knowledge, and the ability to apply critical thinking to the case facts are essential skills for the CDI specialist. While serving as a record of care, it provides valuable medical insight and is a vital source of practice management. Perform in-house chart reviews quarterly for maximum production.

See below price plans offered by Pro Initiative Billing Svcs. for these services:

Chart Review
  • per provider 1 date of service
Chart Review
  • Up to 10 providers 5 dates of services

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