CDI best practices: Capturing the true clinical story

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CDI best practices: Capturing the true clinical story

By Patty Buttner

Clinical documentation improvement (CDI) ensures a true clinical “story” is captured in the health record by improving the integrity of healthcare data and providing a clearer representation of the care and services provided by an organization, and its impact on the health of the population. Over the past few decades, CDI has grown and evolved as healthcare leadership recognized that accurate data in both inpatient and outpatient settings is vital to organizational success. Healthcare data is not only used for reimbursement purposes, but for strategic planning, population health data, patient outcomes and quality of care, as well as a host of other uses.
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Recommended best practices to guide the CDI process include:

Focus on the integrity of the health record
Coding professionals rely on accurate healthcare information in order to assign diagnosis and procedure codes to reflect the entire patient picture in numeric and/or alphanumeric codes. These codes are then used for reimbursement, regulatory compliance, accreditation and several other purposes. It is imperative that these codes are accurate and a CDI program can help ensure accuracy.

Involve staff from a variety of disciplines
CDI professionals may come from various backgrounds, such as health information management (HIM), nursing, and physician practices. Each discipline brings with it a unique set of skills to enhance the role. There is fundamental knowledge that must be known or learned in order to succeed in the role as a CDI professional as they proceed through the record review process and establishment of diagnosis and/or procedure codes, as well as communication with various healthcare professionals.

Knowledge and skills needed include:
• An understanding of anatomy and physiology
• Knowledge of pathophysiology
• ICD-10-CM, ICD-10-PCS, CPT and HCPCS coding
• Effective communication skills
• Excellent critical thinking skills

The query process
CDI professionals review the health record documentation to determine if it accurately reflects the health status of the patient, the resources utilized to care for and treat that patient and if this information can be translated into coded data. During the review they may discover opportunities to obtain clarification from the provider.

The common tool utilized by CDI professionals is the provider query. This tool is the main communication tool when the CDI professional identifies a query opportunity. There are best practices for when a query is indicated; the following list includes examples of when it may be appropriate to query the provider.
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