With the help of a Clinical Quality Management System, an entire practice staff takes part in increasing the quality of care that is delivered to their patients. This system lets a care team know the status of each of their patients regarding required preventive, screening, and chronic disease management services that are based on practice-specified care guidelines. It acts as a tool to reach patients at the point-of-care and it ensures that staff manages the entire patient population effectively and efficiently.
All the regulations prescribe policies, procedures and responsibilities for the administration of the Clinical Quality Management Program including DOD, and constitutional policies addressing medical services quality management requirements. PDN provides on-site and off-site medical billing and medical coding services, and clinical quality management of medical documentation. Contact us for medical coding services.
Promoting quality patient management is mandatory under clinical quality management systems, and requires that contracted practitioners adhere to reasonable practice parameters (PDN provides healthcare management personnel for consulting as well). Diagnosis/evaluation and treatment are two significant parameters of clinical decision-making for quality management system. The practitioner must demonstrate a clinically suitable approach to his/her clinical decision-making processes. This approach is dependent upon the clinical awareness and the experience of the practitioner in his/her respective field. Best practices for quality patient management and coding depends on the professional’s skill in clinical appraisal, deductive reasoning, as well as a pattern of recognizing patient safety,( i.e., the avoidance, recognition), and also the management of adverse outcomes assists the practitioner in understanding the level of evaluation and documentation that is suitable. And the practioner assesses how this documentation reveals clinical practices consistent with legal practice parameters, and management of expected clinical outcomes. The clinical data that is in the submitted documents serves as the basis for the clinical service manager’s assessment of the practitioner’s clinical decision-making (in terms of clinical quality services management conclusion and treatment utilization). Learn about PDN’s clinical quality management consulting services.
To satisfy the clinical quality management system requirements, the practitioner must include adequate patient demographic information enabling him to identify the patient accurately. In the event that the documentation either lacks accuracy, or is incomplete, the clinical services management administration staff can contact the practitioner for all the required clarification as the practitioner is allowed the opportunity to provide the necessary information upon requirement, and failure to do so could result in an administrative non-approval of the submitted treatment/services. Upon successful administrative review, the documentation is then sent to a licensed, and peer clinical services manager for verification purposes. Treating practitioners are also expected to have constant communication with a referring health care provider, wherever applicable, and co-management of the patient’s episode of care among practitioners is expected. Some factors like surgical procedures, patient’s age, medical history, responses to earlier treatment, occupational factors, etc., may affect the expected response of the member considered.
All the cases with respect to clinical quality management system are evaluated considering all relevant clinical evidence for that patient’s unique clinical situation. It is understood that similar case studies may be handled with a similar approach and that too with reasonably consistent results. For a given diagnosis, the effect of variability in general health status considering age, gender, past medical history, psychosocial factors, and presence of co-morbid conditions, etc., makes the use of diagnosis-specific treatment duration and frequency limits inherently untenable.