Clinical Documentation Integrity- Advancing as a Profession




As many of you are aware, I have been advocating passionately for a total transformation of current CDI processes that have virtually remained stagnant for the past twelve plus years. This transformation in CDI requires a two-pronged approach to be successful in execution, the first consisting of rebranding and reformulation of current CDI processes that have demonstrated over time to be ineffective in achieving any meaningful, measurable, sustainable improvement in physician documentation that is noticeable when reviewing any patient record. The second key component for ensuring a successful CDI transformation within any existing CDI program consists of the CDI professional taking the initiative to equip themselves with the requisite skill sets and knowledgebase to become a true “facilitator” in true “Documentation Integrity,” being able to work hand in hand with all physicians as mentors and coaches in advocating for, promoting, and providing guidance and learnings on best practice standards and principles of documentation that support fully informed patient care communication with appropriate optimal reimbursement as a byproduct of complete and accurate physician documentation.


I would like to discuss the topic of advancing your career in CDI, going from what I refer to as a standard CDI to an advanced CDI that seeks and recognizes the critically important role a CDI can play in achieving complete and accurate physicians/provider documentation. The advanced CDI professional recognizes and treats the medical record as a communication tool first and foremost versus what I see today primarily is seeing and treating the record as a reimbursement tool. I am certainly not downplaying the importance and necessity to ensure optimal reimbursement for each patient encounter, whether it be the Emergency Department, physician office, urgent care, observation, or inpatient. Just the same, the advanced CDI professional can effectively review the medical record, identify true opportunities for documentation improvement that support not only a capture of a diagnosis but also even m ore importantly support the best practical approach of communicating the patient care provided for fully informed, coordinated quality focused patient centered cost-effective care. By focusing upon achieving measurable, meaningful, sustainable documentation integrity, optimal reimbursement will be attained that is certainly less prone to take backs and denials from payers with compliant documentation, coding, and billing to boot.


I have been advocating for a total transformation of current CDI processes for some time now and wanted to today offer you some guidance and thoughts on how to become a role-based CDI professional, advancing your career potential in CDI. What do I mean by role-based CDI? Role based CDI means migrating away from queries as the basis for CDI. Queries are certainly needed to address clarification of documented diagnoses or to seek documentation of clinically relevant diagnoses that may have been overlooked in existing physician/provider documentation. A role-based CDI professional can take the chart review process one step further, being able to review the record and identify any documentation insufficiencies detracting from capturing, reflecting, describing, telling, and acutely reporting the patient story. This means being able to start a chart review process beginning with the ED record, proceeding to the H & P, progress notes and discharge summary, reviewing the record as the patient progresses during the hospitalization until the patient is discharged home or to a post-acute care setting. As my colleague Dr. John Zelem continues to state, without clear and convincing documentation of the need for hospital level of care as an inpatient status, there is really no need for CDI, they don’t need to get involved. So, let’s look at how and where they can start in beginning the transition from task based to a role-based CDI professional.


CDI- What is holding back the achievement of clinical documentation excellence, that is a record where a physician or other provider can pick up a chart at any given time and assume care where the previous physician or other provider left off without having to review every previous patient note. The CDI industry has established as the general approach to CDI review of the record for diagnosis or diagnoses in addition to clarifying PSIs, HACs, core measure reporting, and other quality measures. Now, there are a minority of programs that are migrating away from strict diagnosis reporting to embrace processes that move documentation in the right direction with accuracy and completeness. Advancing CDI as a profession requires the CDI professional to acquire the necessary skill sets, core competencies and knowledgebase to be able to confidently review a record for completeness and accuracy, identify insufficiencies and work directly with physicians and other providers to address in a collaborative educational based manner. Where does the CDI professional look to acquire this knowledge and skill sets? Let me provide you with some areas where this knowledge may be acquired and learned. First, one must be knowledgeable in standards of documentation from an E & M standpoint, Evaluation and Management standpoint. I am not referring to E & M from a coding and billing perspective, instead from a documentation standard perspective. A good resource to understand and learn about these standards of documentation is the CMS Evaluation & Management Services Guide, this was just updated in February 2021. You can download the service guide by searching for the document in Google or another search engine. Please take the time and read this very informative service guide. There are a host of other resources I highly recommend to acquire this knowledge and skill sets, become more relevant in clinical documentation and maintain commitment to CDI. Check out my website, Core-CDI.com or the Top Gun Audit School website, TopGunAuditSchool.com as well. I am a Co-Founder of Top Gun with Ernie de los Santos the Founder and Creator of Top Gun. There are over twenty CDI related webinars and other resources Feel free to reach out to me for guidance and advice on how best to start the critical process of advancing your career in CI as a true CDI professional that not only adds value to your health care organization but also advances your potential to become more marketable in the marketplace. Of course, let’s not underestimate the value of true clinical documentation integrity to the patient, the physicians, and all healthcare stakeholders participating directly or indirectly in the patient’s care.

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