Clinical Documentation Toolkit Questions And ANSWERS (A+ GRADED)

Clinical Documentation Toolkit Questions And ANSWERS (A+ GRADED) What is CDI? - ANSWER Any manual or electronic notation made by a clinical care provider or their authorized "medical scribe." What is the purpose of CDI? - ANSWER The diagnosis and procedures documented in the record need to be clearly supported by clinical indicators so that the ICD-10-CM/PCS codes assigned are accurate and correctly assigned. Written Query - ANSWER The method of clarification used by CDI professionals. Verbal and electronic are also methods documented in the health record to make contact with the Physician. Benefits of CDI Program - ANSWER Accuracy and completeness in documentation, coding, reimbursement and severity of illness [SOI] and risk of mortality [ROM] classifications. How to begin a CDI Program - ANSWER A focused concurrent review of a specific payer type (such as Medicare) or payment type (such as DRG). Where are CDI Programs found? - ANSWER CDI programs are typically found in the acute inpatient setting, they also exist in other healthcare settings such a provider offices, ambulatory care, acute rehabilitation hospitals, amd skilled nursing facilities. Who are the CDI staff? - ANSWER HIM Coding Professionals, Nurses, Provider Liaisons or Provider Champions who conduct reviews and communicate with other providers on documentation issues. Knowledge, Skills, and Attributes of CDI Professionals - ANSWER Clinical Knowledge Payment Systems Methodologies ICD-10-CM/PCS Coding Concepts and guidelines, Regulatory Compliance, experience in Hospital acute care, and strong verbal and written communication skills. Terms for "CDI Professionals" - ANSWER CDIP: Clinical Documentation Improvement Practitioner CDIS: Clinical Documentation Improvement Specialist CDS: Clinical Documentation Specialist Who are Key CDI Stakeholders? - ANSWER CDI programs are seen as a bridge between a host of professionals HIM and Coding Departments Case Management and Utilization Review Medical Staff and Provider Leadership Executive Leadership Patient Financial Services or Billing Finance and Revenue Cycle Quality and Risk Management Nursing Compliance and Ethics CDI Goals - ANSWER Obtain clinical documentation that captures the patient SOI and ROM Identify and clarify missing, conflicting, or nonspecific provider documentation related to diagnosis and procedures Support accurate diagnostic and procedural coding, MS-DRG assignment, leading to appropriate reimbursement. Promote health record completion during the patient's course of care, which promotes patient safety Improve communications between physicians and other members of the healthcare team Provide aware3ness and education Improve documentation to reflect quality and outcome scores Improve coding professionals clinical knowledge What is the CDI Concept that must be part of the CDI formula to achieve sustainable and cost-effective success? - ANSWER CDI educational component that is supplemented and complemented by usable, efficient, compliant, and meaningful documentation tools that enhance provider optimal patient care workflow enhances one's success,