Building a Clinical Documentation Improvement Program

When building a Clinical Documentation Improvement (CDI) program for your medical practice, make certain that you set specific goals. Keep in mind the goal is to improve documentations, coding, and reimbursement. I recommend you begin with these goals in mind when building your program

• Aim to establish a well-organized medical practice
• Produce reliable medical records that can help enhance the quality of care for the patients
• Promote the profitability of the provider
• Develop a query process to clarify coding ad documentation
• Provide guidance and direction to the providers as to documentation expectations
• Audit and monitor continuously
• Stay on top of coding and carrier guidance

There are three general processes that you should take into consideration:

1. Assessment
• Evaluate current systems in place for clinical documentation
• Conduct a baseline medical record audit to identify areas that may require:
            • Improvement
• Corrections
• Make physician education, training, and briefing part of assessment process
• Set specific goals and expectations for the providers and the practice
• Keep types of audits separate
• Diagnostic procedures
• Therapeutic procedures
• E&M and consultations
• Focus on level 1-5 visits
• Don’t just target level 4 and 5
• Reimbursement could be missed
• Review bell curve data and practitioner utilization
• Diagnosis coding to support medical necessity and to support ICD-10

2. Implementation
• Collaborate via a CDI provider to implement the needed changes in the best way possible wherein everyone can smoothly adjust
• Make everyone aware of the importance of a certain task
• Pre-planning is the initial step where everything needed such as the tools, work spaces, personnel, templates, etc., is prepared for successful implementation
• Carry out a customized program based on the results of the audit
• Provide the necessary education to local practitioners in preparation for the maintenance or sustaining process
• Implement the needed changes, based on the suggestions of a well-planned audit, while every move is closely monitored by a dedicated staff member
• Evaluate the effectiveness of the CDI tasks to identify area that may require further improvements or evaluations

Queries are a valuable piece of CDI implementation. A query is a question posed to the physician to obtain additional clarifying documentation in order to assign a procedure or diagnosis code. Query responses can be documented in the progress note, discharge summary, or a query form that is kept as part of the permanent record. Queries must be: clinically based; fact driven; concise and to the point; and not leading.

Queries should be done whenever there is conflicting, ambiguous, or complete information, or regarding any significant procedure, condition, or reportable event. Queries should not be done to question a provider's clinical judgment.

In addition to developing a query process, the practice must assign a staff person or CDI practitioner to monitor and manage the queries, including deciding a format (e-mail- or software-based, Intranet, etc.) and tracking the number and types of queries per month by practitioner to identify those who might need more help with their coding and documentation.

3. Maintenance

Maintaining the CDI program is critical to its success. The CDI program should be maintained by the local practitioners and administrators. To ensure the sustainability of the program, the provider or consultant should stay closely involved with:

• Monitoring;
• Continuing education;
• Additional audits; and
• Adjustment programs.

Conclusion
Monitor improvements and deficiencies. Educate practitioners who fall below accepted standards set by the practice. Make sure your compliance plan is active along with the CDI program and both are working and breathing documents.

To overcome the CDI challenges just like with any other goals, it should start with proper awareness and motivation. In this case, appropriate physician training and clinically oriented education should be provided. Hire a reliable provider of clinical documentation improvement programs who can collaborate with local practitioners effectively. By having a team of specialists who can impart CDI solutions, the exact needs of the facility will be matched to the appropriate solutions. Invest on training tools and materials that are needed for documentation. This way, physicians and nurses can document properly.

Deborah Grider, CDIP, CPC, CPC-I, CPC-H, CPC-P, CPMA, CEMC, CCS-P, is a senior manager for revenue cycle at Blue & Co. LLC. Grider is a nationally recognized author of American Medical Association Publications, including "Principles of ICD-9-CM," "Coding with Modifiers," "Medical Record Auditor," and "Principles of ICD-10-CM and the ICD-10-CM Workbook." She is a healthcare consultant with over 32 years of coding, billing, practice management, and Health Information Management experience. E-mail her here.