Clinical Documentation Improvement Assignment

Overview/Description of the CDI

Clinical Documentation Improvement (CDI) refers to the process of reviewing medical record documentation for accuracy and completeness. CDI can also be defined as the process of improving healthcare records to create accurate reimbursement, better patient outcomes, and higher-quality data. It includes a review of diagnostic findings, disease process, and what the medical record documentation could be missing. CDI involves multiple specialists with both medical and clinical coding backgrounds. Their main role is to ensure that proper standards of medical recording and documentation are maintained.

The Benefits of Implementing a CDI Program

Implementing a CDI program in a healthcare organization is very beneficial. First, A CDI program can enhance the accuracy of billing and coding for healthcare facilities, which can result in more accurate reimbursement. A CDI program is also associated with reduced claim denials. By utilizing a CDI specialist, a healthcare organization will ensure that medical claims are easy to understand, thoroughly complete, and filed on time, reducing the possibility that a medical claim will be denied by the insurance company. The implementation of a CDI program can also improve the quality of patient care. CDI usually ensures EHR data correctly reflects the patient’s diagnosis. It also enhances communication between healthcare providers. Lastly, A CDI program can reduce physician queries. Physicians’ documentation usually affects other departments, including the coding and billing department. Coding professionals tend to review physician documentation on a patient assigned CPT (Current Procedural Terminology), as well as, ICD (International Classification of Diseases) codes. A CDI program can, therefore, help reduce mistakes, illegibility, and incompletion in clinical documentation, thereby, reducing physician queries.

Consequences of not Implementing CDI

Failure to implement CDI can mean incomplete, inaccurate, and illegible documentation. This can result in claim denials, which usually occur due to clinical documentation mistakes, illegibility, and incompletion. Incomplete and inaccurate documentation can also adversely impact the quality of patient care. This can lead to longer lengths of stay, higher readmission rates, and increased healthcare costs. Incomplete and inaccurate documentation can also increase physician queries. In instances where the patient records are incomplete, unreliable, conflicting, and illegible, coding professionals will need to contact healthcare physicians for more clarifications.

Elements of sound Health Record from the CDI Perspective as they relate to Quality Documentation Practices

• Accuracy of the Health Record: A sound health record should reflect the information provided by the concrete source (Med League, 2013). The accuracy of medical records is influenced by many factors, including the patient’s emotional and physical health during data collection, documenting and interviewing skills of the healthcare professional, dependability of equipment utilized for diagnosis, and the reliability of medical systems utilized to collect and store information.
• Clarity of the Medical Record: A sound health record should be clear. In other words, it should be easy to understand and interpret, reducing the risk of medical errors. Medical errors are among the leading cause of death in the United States alongside cancer and respiratory disease.
• Consistency: A sound health record should be consistent. It should not contain any sentences or words that might be interpreted as inconsistent with the procedure performed or diagnosis assessed.
• Completeness: A sound health record should be complete. Healthcare physicians should strive to document all information related to the patient’s diagnosis, including any changes in health condition and any current medications
• Timeliness of Medical Record: A sound health record should be timely. The health record should reflect current information. Failure to maintain timely and current information can adversely affect the treatment and care prescribed for the patient.
• Accessibility of the health record: A sound medical record should be easily accessible. Accessibility is all about the ease with which the medical record can be obtained. Accessibility can be impacted by several factors, including the way health records are arranged and organized (Med League, 2013). Healthcare providers should properly organize health records to ensure easy access.
• Legibility: A sound medical record should have the ability to be understood and interpreted correctly. Illegible health records can be detrimental to patient care and can also leave physicians vulnerable to lawsuits (Murray et al., 2012). Medical records are important documents that must be able to be read, understood, and interpreted.

The Significant Role of Physicians as it relates to Timely, Accurate, Complete, and Legible Health Record Documentation Practices

Healthcare physicians play a key role in maintaining timely, accurate, complete, and legible health record documentation. Physicians should maintain timely and current medical information. Failing to do so can be detrimental to patient care and treatment. Physicians should also maintain accurate medical records. Maintaining accurate health records is a fundamental element of providing safe patient care. Maintaining accurate health records can also reduce and mitigate the likelihood of having a malpractice claim. Additionally, healthcare physicians should maintain complete health records. Accurate and complete medical records can ensure the patient gets proper care at the right time. Maintaining legible health records is also important. Physicians should be able to autonomously understand medical records and use them to make decisions. Medical records must be shared between healthcare physicians, and a legible record facilitates that process.

Physicians must also ensure timely responses to physician queries. A physician query is a process of communication used by a medical coder, biller, or clinical documentation improvement specialist to request clarification of a patient’s diagnosis from the healthcare physician. The AHIMA (American Health Information Management Association) defines a physician query as a process or communication tool utilized to clarify documentation within the health record for accurate coding and documentation integrity (AHIMA, 2013). A timely response to physician queries is very important in a healthcare organization. It ensures the organization, as well as, physicians receive proper reimbursement for medical services. Unanswered physician queries can lead to unprocessed claims.

The Physician Query Process

The physician query process involves several steps. The process begins when a medical coder, biller, or clinical documentation improvement specialist sends a query to the physician through an email, text, or phone call (Chartier, 2014). The physician will then log into the EHR system, locate the patient’s chart, create an addendum to the medical record, and respond to the coder or the clinical documentation improvement specialist. On average, it takes fifteen to twenty minutes to address a single physician query.

How the HIM Department will lead the Initiative

The HIM department specializes in the process of acquiring, examining, and protecting traditional and digital medical information necessary in the provision of quality patient care. The main role of the department is to organize traditional and digital records received from physicians, patient forms, or diagnostic laboratories and ensure that data is complete, accurate, secure, and timely. Written documentation is normally converted to electronic form to make it easier to track medical records.

How the HIM Staff will assist the Chief of Staff and the Entire Pool of Practicing Physicians

The HIM professionals play a key role in medical documentation. They work with physicians to help enhance medical data collection, improve healthcare quality, and maximize reimbursement (Bailey-Woods et al., 2014). Healthcare physicians are paid by government payers or insurance companies through a reimbursement system. Often, most physicians do not realize the connection between proper clinical documentation and proper reimbursement. Many tend to make coding mistakes. And as we all know, coding mistakes can lead to fines and other administrative consequences.

HIM professionals are skilled in clinical documentation and coding. They know what to include in an insurance claim to capture everything. That is why physicians need to work with them, specifically those in charge of clinical documentation improvement and coding. The aim is to capture the data needed to ensure appropriate reimbursement.

Conclusion

Clinical documentation improvement is very important in a healthcare organization. CDI can enhance the accuracy of billing and coding for healthcare facilities, which can result in more accurate reimbursement. CDI can also improve the quality of patient care. A CDI program can also reduce physician queries. However, failure to implement a CDI program can mean incomplete, inaccurate, and illegible documentation, which can result in claim denials, poor quality of care, and increased physician queries. Physicians have a role to maintain timely, accurate, complete, and legible health record documentation. They must also ensure timely responses to physician queries. A timely response to physician queries ensures the healthcare organization and physicians receive proper reimbursement for medical services. Healthcare physicians should work with trained HIM professionals to ensure appropriate reimbursement.

References

AHIMA. (2013). Physician Query Examples. Retrieved from: https://journal.ahima.org/page/physician-query-examples

Bailey-Woods, L., Dooling, J. A., Fabian, D., Kuehnast, T., Luthi-Terry, S., Raymond, J., … & Westhafer, K. J. (2014). Roles for HIM professionals in HIOs. Journal of AHIMA, 85(8), 46-49.

Chartier, H. (2014). Designing an Emergency Department Physician Query Process at Franklin Memorial Hospital (Doctoral dissertation, The College of St. Scholastica).

Med League. (2013). 6 Key Attributes Of A Medical Record. Retrieved from: https://www.medleague.com/medical-record-legal-nurse-ehr-expert-emr/

Murray, S., Boylan, G., O’Flynn, S., O’Tuathaigh, C., & Doran, K. (2012). Can you read this? Legibility and hospital records: a multi-stakeholder analysis. Clinical Risk, 18(3), 95-98.

Appendix

Based on the week 3 assignment “Health Record Documentation Policy” and week 4 assignment “Data Quality beyond Borders: Modernizing Health Information Infrastructure Using AHIMA’s Data Quality Model”, it is evident that proper use of abbreviations in clinical documentation is very important. Inappropriate use of abbreviations can be detrimental to patient safety as it may lead to medical errors. It is also important to ensure the security of medical information and data. Some of the characteristics of quality data include accuracy, accessibility, comprehensiveness, consistency, currency, definition, precision, relevancy, timeliness, and comparability.