Frank Jurcak, MSN, RN, CCDS, CCDS-O, the Chief Clinical Strategist for Iodine Software, brought the goods on the secrets of mid-revenue cycle management. With hospitals operating on tighter and tighter margins, clinical documentation improvement programs (CDIs) must optimize to take advantage of every savings opportunity.

“Healthcare systems are truly on very tight margins now, and that requires real close attention to efficiency and appropriate utilization of resources,” Jurcak explained. “So, with the increasing demands put on accuracy and depth of documentation, records need to be reviewed daily to identify discrepancies between the clinical evidence and the accuracy of the documentation.”

Because human resources are at a premium in healthcare, there are not enough people to keep up with the need for this type of daily review. Between documentation, changing regulations, and new evolving technology, it isn’t easy to know what to do next

Accuracy is the name of the game in all aspects of healthcare, especially in the documentation. “Documentation drives the final reporting of codes, and without that clear, consistent, and complete documentation, it’s impossible to accurately code what’s really happening and results in inaccurate reimbursement,” Jurcak said.

So, what can healthcare organizations do to minimize documentation leakage and increase accuracy? “To solve this leakage issue, you got to focus first on documentation integrity across all records,” Jurcak said. “We can’t be targeting a particular metric or particular condition to say this is how I’m going to solve all problems because it’s only solving a very small problem.”

According to Jurcak, AI technology could play a role in assisting by emulating the clinical brain of a provider and in the identification of the correct records.