2104 Title: Documenting Excellence! Justify Length of Stay and Increase Your Case Mix Index Date / Time: Thursday, June 10, 2010 at 02:30 PM - 04:00 PM Type: CONCURRENT Level: INTERMEDIATE Sponsor(s): - Speaker(s): Cheryl E. Arford In today's health care, we are faced with increased regulation, oversight, review, guidelines, rules, and reduced reimbursement. As we attempt to perform greater duties and responsibilities, with less staff and the increased acuity of our patients, we must learn to work smarter. A key aspect to working smarter is improving the clinical documentation within the medical record of each and every patient we serve. The appropriate documentation is reflected in the increase of the Case Mix Index (CMI), capture of POA indicators, correct CC and MCC status of the patient, support of the LOS, reduction in payer denials for medical necessity, clearly defining the core measures within the medical record, and preparation for the RACs and the MACs. Additional benefits are improved physician and organizational publicly reported profiles. The goal is ensuring accurately documenting the appropriate severity of illness, intensity of service and treatment provided to every patient, every day, in their respective medical record. Case managers are an important part of the Clinical Documentation Improvement Team along with the clinical documentation specialist, the physician, and the coding professional. Working together they ensure a concurrent, accurate, well- documented medical that will stand the scrutiny of all oversight bodies. In this session, you will learn how to:  1)  Identify seven key indicators for a Clinical Documentation Program;  2) Describe five responsibilities of the Clinical Documentation Specialist; and  3) Delineate the benefits to case management of a Clinical Documentation Improvement Program. Objectives: Identify the elements of a successful clinical documentation improvement program. Discuss the benefits of a complete, clinically accurate, compliant medical record. Describe the collaborative efforts necessary to achieve documentation excellence.