Question

Write a one page narrative explaining the importance of Clinical Documentation Improvement (CDI), how CDI relates to coding, and the tools used to implement and sustain a CDI program.

Answer 1

Organizations strive to continuously improve their clinical documentation through organized clinical documentation improvement (CDI) programs (realizing that strong CDI program means hiring and training skilled CDI specialists). The purpose of a CDI program is to perform reviews of documentation for conflicting, incomplete, or nonspecific provider documentation. These reviews can be done in a concurrent and retrospective manner, with reviews usually occurring on the patient care units. These types of programs are designed to improve documentation, coding completeness, reimbursement, and severity of illness in the classification process.

A variety of individuals may perform this function, but it is commonly assigned to health information management (HIM) professionals, coding professionals, physicians, nurses, and other professionals with a clinical and/or coding background. Certainly good communication with the provider is required, and much of it may occur through the physician query process.

Clinical documentation improvement programs utilize professionals who focus on the accuracy of clinical documentation. The CDI professional, often referred to as a clinical documentation specialist (CDS), may have either a coding or clinical foundation but is able to mesh both skill sets. CDSs may come from diverse backgrounds and possess a variety of credentials, such as a Registered Health Information Administrator/Technician (RHIA/RHIT), a Certified Coding Specialist (CCS), a physician, or a nurse. In addition, the CDS may hold Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) certifications. A CDS must be able to work cooperatively, building rapport and trust with providers and other staff.

The CDS performs a concurrent and/or retrospective chart review to determine if further clinical documentation is needed to capture the most accurate clinical picture of the patient. In order to accurately code the patient health record, the chart requires clear and specific documentation by the physician. The record review may include notes from diagnostics, emergency room, operating room, nurses, therapy, and other disciplines. The reviewer must compare these notes to the documentation in the history and physical, consultant notes, and physician progress notes. If the information is not complete or if there is a discrepancy in the patient health record, the CDS should query the physician for additional or clarifying documentation in the record. The CDS may need to query for reasons such as:

•Legibility

•Completeness

•Clarity

•Consistency

•Precision

The focus of CDI is improving the quality of documentation to help ensure an accurate and complete reflection of the patient's care, comorbid conditions, and treatment—which impacts severity of illness (SOI) and risk of mortality (ROM). For example, if the patient has a urinary tract infection (UTI) with kidney insufficiency, the SOI or ROM could be low. However, if the same patient has a UTI and acute kidney failure documented, then the SOI and ROM could be higher due to the greater specificity of the kidney diagnosis. Complexity and severity of illness is reflective of the supporting physician documentation provided.