Best Practices for Clinical Documentation Improvement: Techniques and Technologies
(Editor's Note: This guest blog was written from AHIMA 2012 by Karen Kostick, RHIT, CCS, CCS-P.)
What happens when a HIM professional and physician share the same clinical documentation improvement (CDI) mission? Results.
Together, Dr. Jon Elion, CEO and founder, ChartWise Medical Systems Inc., and Darice Grzybowski, MA, RHIA, FAHIMA, president, founder and principal consultant of H.I.Mentors LLC, presented their clinical and HIM perspective on CDI best practices at AHIMA's 84th annual Convention and Exhibit in Chicago.
They emphasized the mission of a CDI program is to improve clinical documentation that results in quality health information. CDI decisions are not to be made to improve reimbursement. As explained by the presenters, if you go after reimbursement, you'll miss the quality health information. However, if you go after the quality health information, proper reimbursement will follow.
Some of the CDI best practices shared by the presenters include:
- Fully understand your current documentation workflow process.
- Set up metrics to measure performance, which include measures on query response rate and turnaround time, concurrent vs. retrospective query rates, and DRG change rates.
- Ensure adequate training and education is in place for the physicians, physician champion/liaisons, coding staff and CDI specialists.
- Dedicated staff performing CDI is recommended as well as employing certified CDI specialists through professional associations such as AHIMA and ACDIS.
- Teamwork is critical between retrospective coding staff and concurrent CDI specialists.
- Goals in querying include 2/3 Concurrent, 1/3 Retrospective and 100 percent physician response rate.
- Understand current strengths and weaknesses of a CDI program so that improvement initiatives can be targeted in specific areas such as a specific diagnosis or targeted patient populations.
- CDI software tools such as Computer-Assisted Clinical Documentation Technology (CACDI) is essential to assist with streamlining workflow processes and advanced reporting, and other functionality vital in maintaining a best practice CDI program.