Your Clinical Documentation, Improved!
Clear, concise documentation of patient encounters is pivotal for both appropriate reimbursement as well as quality reporting. As documentation complexity increases with ICD-10, the need for organized Clinical Documentation Improvement (CDI) initiatives increases with it. Couple this with the RAC-Attack, where auditors are recovering millions of dollars of reimbursement from poorly documented encounters, and the need for CDI is evident.
BayScribe provides tools that enable CDI staff to efficiently identify and review cases, prioritize and manage their case-load, easily communicate with Coders and Physicians, and ultimately, achieve appropriate reimbursement. BayScribe provides easy access to all of the pertinent encounter notes – dictated and transcribed reports, handwritten notes & electronic notes — side-by-side for timely review and query.
An extra set of eyes
BayScribe v6 is like having an extra set of eyes reviewing your clinical documentation. Specificity is widely recognized as a leading query. In some facilities, Specificity accounts for greater than 20% of all queries. BayScribe automatically identifies reports that are lacking appropriate specificity and informs the CDIS, which creates substantially improved efficiency.
Examples of ‘Unspecified’ Filters include:
- Anemia Unspecified
- Angina Unspecified
- CHF Unspecified
- Dementia Unspecified
- Encephalopathy Unspecified
Potentially ‘undocumented’ secondary diagnosis are also identified for the CDIS. Often, the focus of the documentation is on the principal diagnosis, and although the secondary diagnosis(es) are likely being treated, the proper documentation of that diagnosis may be missed. For instance, a Hypertensive Diabetic who is admitted for Shortness of Breath may also be in Mild DKA (based upon signs, symptoms and pertinent Lab values). The patient will undoubtedly be treated for the DKA, but the documentation may not support the appropriate reimbursement of the treatment… unless the CDIS catches it. BayScribe catches it in case your CDIS doesn’t!
Examples of ‘Undocumented’ Filters include:
- Acidosis Undocumented
- Acute Respiratory Failure Undocumented
- Acute Blood Loss Anemia Undocumented
- Alkalosis Undocumented
- DKA Undocumented
- GI Bleed Undocumented
BayScribe v6 can quickly analyze every document for every possible unspecified or undocumented (and over-documented) condition you want to find — without calling IT! Quickly and easily identify patients that may have been ‘under’ or ‘over’ documented, as well as ‘missed’ diagnosis… no other CDI tool has this combination of features at a price that is beyond compare.
Watch a quick video overview and then contact us for a private demonstration.