CDI: Easier Said than Done
In January, For The Record published an article on the difficulties and benefits of implementing a clinical documentation improvement (CDI) program. As well as input from me, it includes valuable insights from Drs. William Walker and Jerri Williamson. Including physician input to the article underscores one of the main success factors of any CDI program. That is, the need for physician involvement.
When we say physician involvement we really mean involvement! Peer to peer communication is widely viewed as the best practice in any physician interaction.
Physician champions are essential for training and explaining. They are needed to not just explain the “what” of CDI but also the “why”. Giving good reasons to alter documentation behavior, backed by actual case examples and financial impacts, greatly increases your medical staff’s motivation to change.
Another key point mentioned in the article is healthcare’s natural tendency to link CDI with coding and reimbursement. Instead, I propose that HIM professionals and physician advisors are better served to focus on quality data, accuracy of severity and acuity.
Much of a hospital’s coded information gets translated into publicly available physician ratings and rankings. And since physicians are extremely competitive, they will work hard to protect their image and make sure they are not an outlier of adverse outcomes. Accurate documentation portrays the correct severity of illness of a presenting patient and therefore communicates the correct outcome.
Finally, better documentation improves patient outcomes. All healthcare professionals who subsequently treat the patient see a complete picture of condition and treatment.
In summary, the goal for HIM and CDI professionals is to train and educate physicians about coding and reimbursement implications while also stressing the end product: improved patient care and better quality indicators. Your commitment to these goals, clearly communicated, results in stronger physician commitment and better clinical documentation.
You are right on TB. HIM Depts will tell you it makes everyone’s life alot easier when the Docs are on board and the best way to get them there is to show them the benefits and not the drawbacks. Good words to live by. Thanks.
What is rfeserhing is I’m talking to clinics for self-insured employers and they have vaguely heard of ICD-9 codes and CPTs, but never use them. And that’s 38% of the market these days. I suspect ICD-10 s are just another insurance company’s utilization review tool.