This episode is the second installment about Clinical Documentation and Coding. Today, we have a conversation about Clinical Documentation Improvement with Amber Malone-Wright, Director of Clinical Documentation Integrity at CHESS Health Solutions.
I want to pick your brain about clinical documentation improvement also known as CDI. So tell me amber what is CDI all about?
Well Thomas, I think the main message about CDI is around quality initiatives. Most people who ask providers why good clinical documentation is necessary, many of them are going to say that it's important for the communication to other providers about the continuity of care. Physicians generally understand the need to make documentation legible, timely, complete, and clear and you know with electronic medical records a lot of that is resolved. They also understand that documentation is a legal health record. They understand the common phrase - if you didn't document it, it didn't get done. CDI programs have increased significantly over the past ten years and are predominantly used in the inpatient hospital setting. But now this is expanding into the ambulatory and provider office setting due you value-based care and contract changes. The key is to really just engage providers to correlate how clinical documentation provides an opportunity to demonstrate the quality of care that was provided during an office visit. The American Health Information Management Association or AHIMA really says it best. They say the message to physicians should be: simple good clinical documentation will improve communication, increase recognition of comorbid conditions that are responsive to treatment, and validate the care that was provided, and show compliance with quality and safety guidelines.
Why should a provider change their documentation?
So physicians are taught to ask why as part of a diagnostic training that they went through and the need to understand the reason for a change in clinical documentation in order to fully embrace the concept. So if a provider challenges a CDI recommendation, it's an opportunity to explain why CDI is necessary. Explain the concept around whether it's MSDRG for inpatient or value-based care contracts and how they're designed to increase reimbursement for care of complex patients. It's also important to explain the severity or the illness or risk or mortality score that's derived from the codable diagnosis codes. It's also important that providers understand the process of audits and denials and financial impact. Not only for hospitals but the outpatient office visits as well. Documenting all of the chronic conditions that are known for the patients that affect the care and treatment for that patient impact the medical decision making by the provider and can also impact the level of evaluation and management services.
Amber, tell me how a provider can implement CDI into their workflow?
Electronic medical record technology has really improved the ability for medical records to be legible and timely. Physicians generally use structured templates to input documentation or they can dictate in a standard progress note format. But sometimes, the benefits of the electronic documentation are not always great. Sometimes there are significant challenges with electronic documentation, such as copy and pasting documentation, which can increase the risk of audits including outdated problem lists and then the inability for providers to find the correct diagnosis code in a drop-down selection. It's important to remember that providers are not trained in coding, yet many providers now know the codes that are important for their billing. If the provider chooses a nonspecific diagnosis code to include in the medical record, it could potentially make it more difficult for someone to code the case with a more specific diagnosis code. The EHR creates the opportunity to...
