Clinical Documentation Improvement

CDI

Why?• Your documentation reflects the patient in the

bed, the necessity of clinical diagnostics, the need for continued length of stay (LOS) and the quality of care provided.

• The final coded record, which is the outcome of your documentation, is shared and available to CMS, data mining agencies and insurers. The information is also used by the hospital to evaluate quality, financial performance and healthcare initiatives for the organization.

Phraseology …

• The Clinical Documentation Specialist (CDS) is the liaison between provider documentation and the final coded record.

• The goal of CDI is to make sure the final codes accurately reflect the complexity of the patient.

Remember - we are here for you, to discuss an admission or resource our coding experts to make sure we “get it right”

Descriptors and Diagnoses

Why clarify? ….. • How “insufficient” is it? • Do “mild”, “moderate”, “severe” and

“profound” mean the same to each clinician as a measurable value?

• Do you know that “urosepsis” reflects a simple UTI in coding?

Symptom Diagnoses

• “Change in mental status”• Chest Pain• Syncope• Weakness

Link the suspected or known clinical cause to symptom diagnoses when testing is complete

Continuity …

Example of lack of continuity:• Admission note: “Acute renal failure

secondary to volume depletion.”• Progress note: “renal insufficiency,

dehydration.”• Discharge summary: “patient was admitted

with dehydration…”

Continuity ….

Example of Continuity:• Admission note: “Acute renal failure

secondary to volume depletion.”• Progress note: “Acute renal failure,

improving.”• Discharge summary: “Acute renal failure and

dehydration resolved”

Diagnostic Terms

Clarification of diagnostic terms:• Avoid use of up ↑ and down ↓ arrows for

abnormal lab findings. Instead, use terms such as hyponatremia, hyperkalemia, anemia (and type of anemia)

• Approved abbreviations only … avoid the use of terms not approved.

Present on Admission “POA”

Present on Admission• Every diagnosis is assigned an indicator!• In order to determine whether or not a

diagnosis was present on admission we may ask for further clarification.

• Clarification is important to identify if a diagnosis occurred after admission or was POA … ie: decubitus ulcers, pneumonia, UTI’s etc..

Query Response

• Please respond to physician queries in one of two ways:

• If you agree with the question being asked, please indicate in your progress note and if appropriate re-address in the discharge summary.

• If you disagree with the query, please indicate to us that you’ve seen it.

Clinical Documentation Integrity

If you have any questions about a particular query, or the program in general, please call us. We’re happy to help!