Clintegrity 360 | CDI

Increasing documentation accuracy for physicians

A comprehensive CDI solution with guaranteed results

Based on over 20 years of success, Nuance’s premier clinical documentation improvement program powered by JA Thomas, is a fully managed, end-to-end improvement program that touches all the critical aspects of your institution's clinical documentation process. This begins with an initial assessment of your DRG-based records and documentation needs. Clintegrity 360 | CDI will help you identify clear, measureable objectives for your CDI program. Then, our team will manage every aspect of your clinical documentation improvement program from customizing and integrating the technology tools to ensuring your physicians, nurses, coders, and administrators understand the program and are successfully using it. Nuance will work with you to continually monitor and manage the program to make sure it meets the objectives your organization has set.

Our process


Getting the assessment right is key to clinical documentation improvement. That's why we kick off every project with a 3-4 day clinical evaluation. We bring in a team of clinical and coding professionals to study a statistically significant sampling of your DRG-based records. They closely evaluate how admissions are being categorized according to diagnosis-related groups.

We also bring in our own physicians to meet with key members of your medical staff. They explain how the program works and make the clinical case for Clintegrity 360 | CDI to these members. Our physicians address what the expectations are, how the program benefits doctors, and how Clintegrity 360 | CDI helps improve performance measures. This way, physicians clearly understand the program from the very beginning.

With a proper assessment in place, we can accurately project the impact our Clintegrity 360 | CDI program will have on your CMI. Using these projections, we can guarantee the results of the program. This gives you a clear picture of the project outcomes before the implementation even begins.

Putting our program into practice

Implementing Clintegrity 360 | CDI is an in-depth process. That's why we work closely with you through every step. Our Clintegrity 360 | CDI team comes on site to help put the program in place and guide you through the entire implementation. Here's a brief overview of what's involved.

Comprehensive pre-planning

We provide the tools, templates, best practices, and everything else needed to prepare for a smooth and successful implementation. This includes on-site and off-site guidance and discussion to customize your program, as well as hands-on assistance with testing and interviewing as you hire your Clinical documentation improvement team.

Peer-to-peer education

Our physicians, nurses, and coders work directly with yours to ensure an effective skills transfer. We provide clinically relevant examples and on-the-floor clinical rotations where our experienced professional staff model the Clintegrity 360 | CDI process. We educate all relevant team members on the use of our Clintegrity 360 | CDI software and tools.

Customized physician education

Using clinically relevant examples in the hospital and in your doctors' offices, we clearly demonstrate to your physicians how each of them can personally benefit from learning and practicing Clintegrity 360 | CDI. Our physicians and Part B experts also provide tailored education for large and small groups.

Advanced documentation education

We work closely with your hospital's Clinical Documentation Specialists and HIM Coders to educate them on our 720+ documentation strategies. This involves a combination of formal classroom education and hands-on training. We demonstrate the outstanding results of Clintegrity 360 | CDI through multiple clinical rotations, giving your team a solid understanding of how clinical documentation improvement leads to improved CMI.

Clintegrity 360 | CDI software and tools

We provide state-of-the-art tools and technology, to leverage your team's clinical intuition and support proper documentation. Developed by practitioners, our software is continually updated with the latest documentation strategies and Coding Clinic guidelines. It enables your team to concurrently capture quality core measures and appropriate levels of severity, and enables real-time tracking against best-in-class benchmarks. We also provide other tools, templates, manuals, and pocket guides customized by specialty and roles as needed.

Real-time monitoring

We maintain constant, close monitoring to ensure that the program is being implemented successfully and is delivering results according to plan. This helps to keep everyone on the same page and avoids surprises along the way.

Ongoing support ensures long term CDI success

We stay closely involved after the implementation has been completed to ensure the sustainability of the program. This includes ongoing monitoring, continuing education, and regular evaluation and adjustment. We make sure your physicians and Clinical Documentation Improvement team stay up to date with the latest regulatory guidelines as well as the newest strategies for documentation improvement.

Our ongoing maintenance program includes:
  • Two to four on-site visits in the first year
  • Monthly results monitoring
  • Telephone support for physicians, clinicians, and coders
  • Tech support for Clintegrity 360 | CDI software and tools
  • Annual CMS changes education
  • Customized on-site training (including clinical rotations)
  • Regular software updates (3x per year) to keep up with changing regulations and add extra functionality. This also includes preparation for the upcoming change from ICD-9 to ICD-10 on October 1, 2015.
  • Seminars, e-learning, and peer-to-peer mentoring for physicians (including special programs for resident hospitalists and physician champions)
  • WebEx recorded presentations on special topics, strategies, and clinical conditions
  • Continuing education and training for new employees

Clinical Document Improvement

Clintegrity 360 | CDI is Nuance’s premier Compliant Documentation Management Program, is a fully managed, end-to-end improvement program that touches all the critical aspects of your institution's clinical documentation process.

This begins with an initial assessment of your DRG-based records and documentation needs. We will help you identify clear, measureable objectives for your CDI program. Then, our team will manage every aspect of your program from customizing and integrating the technology tools to making sure your physicians, nurses, coders, and administrators understand the program and are successfully using it.

We stick with you, continually monitoring and managing the program to make sure it meets the objectives you set. Clintegrity 360 | CDI normally pays for itself in a matter of months as it helps you:

Improve Documentation

Unlike retrospective coding-based programs, Clintegrity 360 | CDI gives doctors and nurses education, strategies, and tools that allow them to accurately document each case from the moment a patient enters the hospital.

Improve CMI

Our program gives you a concurrent, clinical process that accurately captures compliant documentation language, complexity levels, and severity levels and ensures that they are reflected appropriately in your Case Mix Index.

Ensure Compliance

All our documentation strategies are fully compliant with The Coding Clinic and ICD-9-CM Official Guidelines. With Clintegrity 360 | CDI, every record contains the compliant language necessary to support appropriate reimbursement and avoid the loss and risk associated with non-compliance.

Improve Quality Core Measures

Clintegrity 360 | CDI Quality helps you identify cases subject to quality core measures in real time and impacts and improves core measure reportable data, enhancing your competitive positioning.

Ensure Appropriate Reimbursements

The more complex and severe diagnoses you manage, with appropriate documentation, the higher your CMI. And the higher your CMI, the better your reimbursement. Clintegrity 360 | CDI maximizes appropriate reimbursements by improving your documentation. It also protects you against the risk of RAC audit liability.

Point-of-entry program

The best way to get the record straight - right from the start

As more and more patients are admitted through your Emergency Department, accurate documentation is becoming critically important. Due to the complexity of ED cases, the hectic work environment and the need to make rapid decisions, in many cases patient acuity is inaccurately reflected by under-documentation of the patient's clinical situation. Staff may accurately document the injury that brought the patient in, but miss secondary diagnoses and/or pre-existing conditions. What's more, a problem list isn't usually created until the patient is moved onto the floor...if ever. Improving the quality of the clinical documentation promotes better communication and creates an opportunity to positively impact clinical outcomes.

JATA has developed a powerful solution and a new clinical staff position to help you ensure better clinical outcomes and accurate reimbursement.

The solution: Clintegrity 360 | CDI Point of Entry Program

Because documentation of critical information starts in the Emergency Department, the Point of Entry program starts there too - evaluating the severity of illnesses, assessing present-on-admission (POA) conditions, determining patient status (observation or inpatient), ensuring compliance with quality core measures, creating a problem list at the point of entry, and enabling more accurate documentation. The Point of Entry program builds on the foundation of Clintegrity 360 | CDI; and takes it even further, providing comprehensive clinical integration management.

New role: Clinical Integration Specialist

With this new solution comes a new clinical role - the Clinical Integration Specialist (CIS). This individual works closely with your clinical team to ensure all clinical observations are documented appropriately from the ED to discharge.

Your CIS is trained to:
  • Perform hands-on patient assessments
  • Identify and secure documentation of POA conditions
  • Assist with quality indicators such as core measures and patient safety indicators
  • Establish a problem list at the point of entry
  • Facilitate accurate, compliant clinical documentation by providing concurrent support to physicians
  • Review medical records for completeness and accuracy
  • Maintain liaison with ED and inpatient case manager and CDS

Contact us today

Clintegrity 360 will help your organization quickly generate substantial revenue and operating savings by ensuring your clinical documentation chain is accurate, sound and fully adopted by physicians.

Engage us

Call 1-877-805-5902 to speak to a clinical documentation specialist today.
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