Clinical Documentation Improvement Program - answer-The purpose of a clinical documentation improvement (CDI) program is to help health care facilities comply with government programs (e.g., RAC audits, ARRA/HITECH) and other initiatives (Joint Commission accreditation) with the goal of improving h...
3-2-1 Code It! Chapter 1 part 2
Clinical Documentation Improvement Program - answer-The purpose of a
clinical documentation improvement (CDI) program is to help health care
facilities comply with government programs (e.g., RAC audits, ARRA/HITECH)
and other initiatives (Joint Commission accreditation) with the goal of
improving health care quality.
-the CDI specialist initiates concurrent and retrospective reviews of inpatient
and outpatient records to identify conflicting, incomplete, or nonspecific
provider documentation.
-CDI programs are usually associated with acute health care facilities;
however, they are also implemented in alternate health care settings (e.g.,
acute rehabilitation facility, skilled nursing facility).
-
clinical documentation improvement SPECIALIST - answer-clinical
documentation improvement (CDI) specialist is responsible for performing
inpatient record reviews for the purpose of:
●implementing documentation clarification and specificity processes (as
part of the physician query process);
● using and interpreting clinical documentation improvement statistics;
● conducting research and providing education to improve clinical
documentation; and
*ensuring compliance with initiatives that serve to improve the quality of
health care, which include:
-complying with fraud and abuse regulations;
-enforcing privacy and security of patient information; --monitoring a health
information exchange (HIE).
coding compliance program - answer-ensures that the assignment of codes
to diagnoses, procedures, and services follows established coding
guidelines, such as those published by the Centers for Medicare & Medicaid
Services (CMS).
-policies (guiding principles that indicate "what to do")
-procedures (processes that indicate "how to do it")
-Policies are written to assist in implementing the coding compliance stages
of detection, correction, prevention, verification, and comparison.
An effective coding compliance program monitors coding processes for
completeness, reliability, validity,
and timeliness.
Detection - answer-the process of identifying potential coding compliance
problems. For example, a coder notices that some patient records contain
insufficient or incomplete documentation, which adversely impacts coding
, specificity. The coder brings these records to the attention of the coding
compliance officer (e.g., coding supervisor), who implements the next stage
of the coding compliance program
Correction - answer-is based on the review of patient records that contain
potential coding compliance problems, during which specific compliance
issues are identified and problem-solving methods are used to implement
necessary improvements (corrections). For example, the coding compliance
officer conducts a careful review of the patient records that contain
insufficient or incomplete documentation. It is determined that all of the
records are the responsibility of a physician new to the practice. Educational
material specific to documentation issues noted during the review process is
then prepared.
Prevention - answer-involves educating coders and providers so as to
prevent coding compliance problems from recurring. For example, the
coding compliance officer schedules a meeting with the physician
responsible for insufficient or incomplete documentation, and educates the
physician about the specific areas of insufficient or incomplete
documentation that adversely impact medical coding. This meeting is
conducted in a non-confrontational manner, with education and correction
as its goals
Verification - answer-provides an "audit trail" that the detection, correction,
and prevention functions of the coding compliance program are being
actively performed.
For example, the coding compliance officer maintains a file that contains the
following:
-Original codes assigned based on insufficient and incomplete
documentation
-Educational materials prepared specific to the documentation issues
-Minutes of the educational meeting with the responsible physician
-Final codes assigned based on sufficient and complete documentation
-Remittance advice from third-party payer, which contains adjudication
(decision about reimbursement, including possible claims denial)
Comparison - answer-requires the analysis of internal coding patterns over
specified periods of time (e.g., quarterly) as well as the analysis of external
coding patterns by using external benchmarks (trends). For example, the
coding compliance officer reviews reports of quarterly medical audits to
determine whether the new physician's documentation has improved. Such
reports contain the results of claims submission, which indicate the number
of claims denials based on nonspecific codes submitted as a result of
insufficient and incomplete documentation. In addition, the coding
compliance officer obtains benchmark data (reports) from third-party payers
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