Content area
Full Text
HEALTHCARE CONSUMERS ARE unique. Each person has his or her own combination of medical conditions that organizations must somehow standardize for data comparison. One way to capture these data is by translating clinical documentation into codes such as ICD-9-CM and CPT.
Historically, in the inpatient setting, data collection occurred after the patient was discharged. After discharge, HIM professionals checked the record for discrepancies that could hinder code assignment. HIM professionals would then query the provider for clarification. (For purposes of this practice brief, the term "query" will be used to identify any physician communication tool.)
However, with the implementation of the prospective payment system, coded data took on greater significance and became a mechanism for reimbursement, quality measure reporting, and profiling. The increased need for interpreting coded data for meaningful comparison and quality reporting has led to the expansion of the HIM professional's role in clinical documentation improvement (CDI).
The focus of most CDI programs is on improving the quality of clinical documentation regardless of its impact on revenue. Arguably, the most vital role of a CDI program is facilitating an accurate representation of healthcare services through complete and accurate reporting of diagnoses and procedures.
A successful CDI program can have an impact on Centers for Medicare and Medicaid Services quality measures, present on admission, pay-for-performance, value-based purchasing, data used for decision making in healthcare reform, and other national reporting initiatives that require the specificity of clinical documentation.
Improving the accuracy of clinical documentation can reduce compliance risks, minimize a healthcare facility's vulnerability during external audits, and provide insight into legal quality of care issues.
This practice brief provides an overview of key elements in establishing, maintaining, or enhancing a CDI program. This can be achieved through a variety of methods and structure that are tailored to the unique needs of the healthcare entity.
The following guidance does not replace the 2008 AHIMA practice brief "Managing an Effective Query Process." It is, however, intended to provide greater specificity and detail related to CDI programs.
Policies and Procedures
The CDI department must be governed by written policies and procedures. These policies and procedures should be developed with the assistance of other departments affected by clinical documentation, including compliance, case management, and HIM.
CDI policies can include...