The Importance of Documentation and CDIP

1. The Importance of Documentation and CDIP Amy Gardner, RHIT

2. What is a Clinical Documentation Improvement Program? • A documentation program that focuses on: • A clinical approach • Concurrent documentation review • Improving documentation completeness, accuracy, and clarity • Documentation Team: • Documentation Specialists • Physicians • Inpatient Coders

3. Determine your mission statement: Mission: Our mission is to facilitate complete, accurate, and timely documentation in the medical record, which will contribute to quality care, reflect severity of illness, justify medical necessity, and allow for appropriate reimbursement for services provided.

4. Benefits of the TDI Program • Increased compliance with OIG, Medicare, and JCAHO regulations • Improved quality of care • Accurate hospital and physician profiles • Enhanced teamwork between the hospital staff and medical staff • Appropriate payments for the hospital and physicians • Hospital’s Case Mix Index (CMI) is more reflective of the types of patients treated by the facility

5. Role of the Documentation Specialist • Assist physicians and other practitioners at the point of service in identifying the detailed documentation needed for timely, accurate coding upon discharge. • Clarify documentation, such as missing, nonspecific, or inconsistent diagnoses by asking questions to physicians either “face-to-face” or in a “query” form. • Educate physicians and other practitioners about factors that affect DRG assignment and case mix index.

6. So what does a Documentation Specialist do? • Perform concurrent review of documentation as it occurs to determine principal and secondary diagnoses • Assign a working DRG based on available documentation at the time of review. • Place a Length of Stay (LOS) form on the chart. They show the physician, case managers and other medical staff the average length of stay for the current documentation.

7. Data Entry

8. Potential CDIP Tools • Software Data Collection • Interfaces to Meditech or other computer database • Produces DRG worksheets and query sheets • Reports • Encoder for DRG Assignment • Coding Clinic References • DRG Expert • DRG Pocket References

9. Physician Queries • Anemia • Chest Pain • Congestive Heart Failure • Digestive System Disorders • Fever of Unknown Origin • Neurological Disorder • Orthopedic • Principal Diagnosis • Pneumonia • Respiratory Failure • Secondary Diagnoses • Septicemia • Present on Admission

10. Building a Team in your CDIP • Meet monthly with DS staff and inpatient coders to discuss the following: • Difficult cases • DRG assignments including initial, DS DRG and final DRG • Query process and outcome • Tracking processes • Education plans for changes • Physician advisor helpful

11. Physician Advisors • Why is an “advisor” helpful • Is “Buy-In” by the Physicians necessary?

12. Educational Opportunities • Physician Education: • Flyers • Emails • “Tidbits” • Place these in places easily accessible to physicians • Brightly colored paper

13. Educational Opportunities cont’d • Presentations • Give examples of impact from CCs vs. MCCs • Verbal Interactions • Attend Meetings with Physicians, Administration

14. Benefits of CDIP • Show what your program provides for your facility… • Severity of illness documentation • Concurrent queries and the benefits of pre-discharge queries

15. Even More Education… • Be willing to talk about your program • How will people know what you do if YOU aren’t willing to tell them?

16. Exciting Times for HIM Professionals • New and exciting field • Be willing to expand beyond the “coding cubicle” • Many growth opportunities for HIM professionals • Keep an open mind and adventurous spirit

17. AHIMA and Queries: Resources • AHIMA Practice Brief: “Guidance for Clinical Documentation Improvement Programs” • Journal of AHIMA 81, no. 5 (May 2010): 45-50 • Managing an Effective Query Process • http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_040394.hcsp?dDocName=bok1_040394