What is Clinical Documentation Improvement?

What is clinical documentation improvement?

By Virginia Bailey RN, CCDS  Education Quality Coordinator – MPU Division

I was introduced to clinical documentation improvement about 13 years ago when I was employed as a case manager in a hospital system with 4 hospitals in the area. A group of us were tasked with some additional work doing what were called “documentation clarification queries” for Medicare patients. It seemed pretty simple at the time. For example, if the doctor wrote “anemia,” but the patient was post-op and had lost over 400cc of blood during the surgery and received a transfusion, we asked if it could be, “acute post-operative blood loss anemia.” At the time the focus was on reimbursement, so if the doctor agreed, then the hospital benefited financially by being able to code that chart for a higher reimbursement.

Eventually, we proved our efforts were making an impact and soon enough we were starting a whole new division called Clinical Documentation Improvement with an initial staff of about 10 of us covering the 4 hospitals. Our main goal at the time was to review the charts of Medicare inpatients concurrently (while they were still in the hospital) and assist the physicians with documenting to the greatest specificity. We were trained on MS-DRGs and what diagnoses resulted in the most specific diagnosis code. We were all critical care RNs, so clinically we understood the process and the impact on not just reimbursement, but on patient care, which is, after all, the best reason to improve documentation!

CDI significantly enhances documentation, thereby positively impacting coding and revenue, but CDI cannot accomplish this alone. Accurate and complete provider documentation is the cornerstone of coding and this documentation should stand on its own – which it often does not. Years ago, CDI divisions were sometimes overseen by the HIM department (coding) and so worked closely with on-site HIM professionals by sharing knowledge and education with each other. Documentation specificity was improving, as were the metrics used to measure the outcomes. CDI divisions were finally proving their worth and being considered part of the financial arm of a facility.

Fast forward to 2018 and that neophyte CDI program is hardly comparable to the CDI programs of today. Today many CDI departments are moving in with the quality department. The push today is for not just better documentation, but complete documentation with no stone unturned in order to provide the most accurate information with which to code the chart, thereby providing evidence that a patient has received the best possible care. This trend toward quality is not new and should not exclude the HIM professionals from the process. Much can be accomplished with the collaboration of CDI, quality, and HIM working side by side.

With this “new” trend, the CDI of today wears many more hats and has an impact on much more than just reimbursement and documentation. The list of programs that a CDI program may impact is extensive. There are HACs, PSIs, KPI, HCCs, AQRP, CQM, ROI, ROM, MEAT, RAF, APR-DRG, risk adjustment, and clinical validation to name just a few! No longer does the CDI “just” clarify documentation, now they need to be well versed in all areas that impact patient care and quality initiatives as these are inextricably linked in both the inpatient and outpatient worlds. Add to that the fact that ICD-10 has made understanding not just the DRGs, but also the details of how to build a code much more important than ever before. The CDI must also be well versed in the coding guidelines for both PCS and CM and be able to recognize not just query opportunities, but also when a query would not be necessary.

All in all, this has made clinical documentation improvement a complete package which can and should be utilized beyond previous boundaries that were largely measured on financial gain.


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