Question

A clinical documentation improvement program has been up and running for six months. Initial training of the CDI staff covered the following:

• Overview of CDI program and goals

• MS-DRGs including CCs and MCCs and their impact on MS-DRG assignment

• The top 10 MS-DRGs for the organization

• What documentation is used for code assignment and where to find in the paper and electronic medical record

• Review of clinical indicators for specific diagnosis such as respiratory failure and protein-calorie malnutrition

1. After reviewing the training program, recommend 4 additional topics that should be covered.

2. Why are these topics important to the CDI program

Answer 1

CLINICAL DOCUMENTATION INTEGRITY PROGRAM( CDI)

• Successful clinical documentation integrity programs facilitate the accurate representation of a patient's clinical status that translates into coded data
• Coded data is then translated into quality reporting, physiician report cards, reimbursement, public health data, disease tracking and trnding and medical research
• The convergence of clinical care, documentation, and coding processes is vital to appropriate reimbursement, accurate quality scores and informed decision making to support high quality patient care
• To that end, CDI has a direct impact on patient care team as well as those who may be treating the patient at a later date.

Additional topics which should be included are:

1.Specificity decision trees and physicians

• Specificity tools can provide correct coding and documentation, but educating physicians on how to adapt and learn these new tools is afluid process
• CDI teams can help physicians navigate specificity calculators during the documentation process and teach them how to apply the tools.

2. Coders, CDI specialist and reimbursement

• Health care systems must know their high volume coding and documentation needs and then bring the right professionals to the table for meanigful discussion that can lead to change

3. Queries and work flow

• There sometimes is a disconnect between how physicians and hospitals view clinical documentation.
• Realigning workflows between the two ensures each party is on the same page. The keys to this realignment are education and communication

4.Audits and education

• Documentation and coding audits have increased under ICD-10.In lieu of payer denials,audits have become important indicators of reimbursement issues that may lie ahead