SLoupe_Module3ClinicalDocumentation­_112123

HIM2000 Module 03 Assignment Clinical Documentation Instructions: Thoroughly complete and submit this worksheet. 1. Explain the purpose of CDI. The purpose of CDI is to improve clinical documentation by reviewing healthcare records for conflicting, incomplete, or nonspecific documentation. 2. List key CDI stakeholders and explain why they are important to the process. The key CDI stakeholders are Health Information Management, Medical Coding and Billing, Case Management, Utilization Review, and Medical Staff and Physicians. They are important to the process, because they each play specific roles during the patient care process. The patient care begins when the patient presents for care, and it goes well beyond when the patient leaves the facility. Each of the departments can impact medical necessity and payment for services. Performing the highest level of efficiency is key in this process. 3. Why are clear cut goals critical for a successful CDI program? Give a couple of examples of meeting goals. Clear cut goals are critical for a successful CDI program to obtain clinical documentation that identifies the patients’ conditions, severity, risk, and medical necessity. A couple of examples of meeting goals is to clearly document the services provided and to identify or clarify missing, conflicting, or nonspecific information. 4. What is the role of queries in the CDI process? The role of queries in the CDI process is that they are used to obtain additional information or missing information. They are a method of communication. 5. What is query management? Query management is the ongoing process of reviewing and monitoring data. 6. What are the CDI tools and how are they used? The CDI tools are designed to help CDI specialist, clinicians, and coders. They are used to set criteria standards and help identify, track, and improve documentation. 7. What are CDI metrics? What is the value of metrics to the CDI process? List 2 or 3 metrics that you feel would be of most value in a CDI program for coders. CDI metrics are methods of measuring, monitoring, and supporting CDI goals and opportunities. The value of metrics to the CDI process is significant. It provides a quantifiable measure to track and trend areas of improvement in clinical documentation. This is important because quality documentation reflects quality care. 3 metrics that I feel would be of most value in a CDI program for coders are query response rate, case mix index, and documentation completion rate. 8. Explain the role of physicians in CDI? In CDI, physicians are required to accurately report their findings during patient care. They also have to provide medical necessity for testing, coding, and billing purposes. 9. Every CDI program startup face challenges. List the six (6) challenges The six challenges addressed in the toolkit are: 1.) Having the right individual performing CDI. Ideally the

HIM2000 Module 03 Assignment addressed in the toolkit. individual would have a background that includes both clinical and HIM experience. 2.) Support from administration for implement and sustain the CDI program. 3.) Physician participation and communication. 4.) Ongoing education for CDI professionals regarding coding and billing guidelines and other legal rule and regulations regarding healthcare. 5.) Clearly defining the CDI process from the coding process. 6.) Communication between CDI, coding, billing, and providers once the patient has been discharged. 10. Which challenge do you think is the most significant? Explain why. I think that the most significant challenge is when providers often consider queries and documentation feedback being took in as on being told how to be a doctor. 11. Every start-up program requires data to make decisions about what the program needs to address. Some examples could include at least 12 months of DRG data, coding issues, denial causes and other case mix data. What other decisions have to be considered and made before implementing a CDI program? Some other decisions that have to be considered and made before implementing a CDI program is an analysis and interpretation of the revenue cycle performance, to target problematic quality reporting, and insufficient documentation. A physician champion should also be selected to promote physician involvement and acceptance. A CDI model and tool should be established in order to develop the best workflow and education program in order to introduce the program. 12. Maintaining a successful CDI program takes more than just reviewing patient charts to validate DRG assignment and working with physicians. What does a successful CDI program require? A successful CDI program requires recorded benchmarks to show a return on investments. 13. CDI programs require skilled personnel. What are the skills or core competencies needed for a CDI Specialist? Some skills or core competencies needed for a CDI specialist is that they should possess a working knowledge of state, federal, and payer specific requirements involving medical necessity, coding, documentation, and reporting. It would also be beneficial if they have nursing or health information management experience. 14. There are a number of techniques CDI professionals can use to reduce denials. List four (4) that you think have the most significant impact on reducing denials. Four techniques that CDI professionals can use to reduce denials that I think have the most significant impact are pre- bill review for denial management, predictive analysis, focus on quality of data and reducing errors, and policies to support the program and the expectation of physician involvement. 15. What do you think is the most significant outcome I think that the most significant outcome of a successful CDI program would be denial prevention and improved