Arrowhead Regional Medical Center

Clinical documentation is integral in improving quality reporting, ensuring reimbursement accuracy, and improving patient outcomes.

Many organizations have implemented clinical documentation integrity (CDI) programs to ensure accurate documentation of patient encounters. The ACDIS offers the following application of its Code of Ethics regarding CDI programs: CDI policies should promote complete documentation regardless of reimbursement implications. CDI aims to improve documentation accuracy and subsequent coding.

Providing patient care with a Clinical Documentation Integrity Specialist

Clinical Documentation Integrity Specialists (CDS) might be unfamiliar to those familiar with risk adjustment from a health plan organization's perspective. CDSs usually collaborate with the care team, working side-by-side with providers. The CDS is proficient at condensing pertinent patient information so that the provider can address relevant conditions. CDI programs aim to accurately measure the burden of illness experienced by patients before, during, and after encounters. The CDI process can assist in clarifying conditions to the highest degree of specificity.

During a 15-20 minute encounter, providers spend about 16 minutes documenting in an EHR, so CDI becomes extremely valuable to them. The CDI program can help providers by highlighting what needs attention during the patient's visit by digesting large amounts of information. The CDS can assist providers in assigning codes concurrently and retrospectively with misaligned coding and clinical logic.

BRIDGING THE GAP BETWEEN CODING AND CLINICAL LANGUES

Coders and physicians speak two languages, which is a significant challenge. The physician's note within the medical record determines the coder's workflow, and Coders can only code if the record contains enough information to document a diagnosis. In most cases, physicians aren't taught how to code and don't understand the coding language.

CDI programs can help close this gap. Consider a stroke as an example. The provider may consider a stroke that occurred a week ago recent if the patient had it a week ago. After a patient leaves the hospital, the coder perceives them as having had a stroke.

A lack of communication can frustrate providers and impede their compliance. The Office of Inspector General (OIG) targets clinical practices that differ from coding practices.

A CDI specialist can be helpful here because they have experience with both clinical documentation and coding. CDSS can verify clinically if a condition exists and if its specificity is recorded.

Social determinants of health and population health could become compliance issues. Providers are becoming aware that non-medical conditions impact people's health and are asking patients about them, but the coder can't code them if the information isn't in the note. Providers may ask questions to get the information, but often the information isn't in a format that coders can use.

In creating a clinical documentation improvement program or trying to comply with regulations, here are some best practices:

Start a CDI program with some pre-work

Examine a sample of records to identify a few areas to concentrate efforts for meaningful change. Demonstrate how enhancing documentation in these areas might help the patient, the practice, or the public. Before creating a program, educate providers. Clinicians must recognize that the administration and the program respect their expertise and time. Physicians and coders must discover a method to collaborate and operate more efficiently.

Choose a physician champion

Finding a respected physician who understands its goals is the key to launching a successful program. The person can promote the CDI program to colleagues and support its mission.

Review the patient's record before seeing them.

The clinical documentation specialist can review the medical record before the office visit for the suspect or outstanding conditions and compliance opportunities. The prospective perspective lends itself to a more clinical perspective than traditional coding.

Process setup

A CDI specialist should review bills with targeted codes before submission to ensure the codes are appropriate. Depending on the documentation, the CDI specialist can change the code accordingly. Patient stories and resources should be accurately captured within the boundaries of compliant coding to capture the patient's experience.

Use technology to enhance the CDI program

Using the right tools can enable more efficient and accurate documentation at the point of care. Integrating provider-focused intelligence tools into the EHR will streamline search and guide physicians to the correct diagnosis code.

Healthcare organizations rely on quality clinical documentation to improve quality reporting, ensure accurate reimbursements and drive better patient outcomes.