Clinical Documentation Toolkit

Clinical Documentation Toolkit What is CDI? - Any manual or electronic notation made by a clinical care provider or their authorized "medical scribe." What is the purpose of CDI? - 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 - 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 - Accuracy and completeness in documentation, coding, reimbursement and severity of illness [SOI] and risk of mortality [ROM] classifications. How to begin a CDI Program - A focused concurrent review of a specific payer type (such as Medicare) or payment type (such as DRG). Where are CDI Programs found? - 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? - 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 - 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" - CDIP: Clinical Documentation Improvement Practitioner CDIS: Clinical Documentation Improvement Specialist CDS: Clinical Documentation Specialist Who are Key CDI Stakeholders? - 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 - Obtain clinical documentation that captures the patient SOI and ROM Identify and clarify missing, conflicting, or nonspecific provider documentation related to diagnosis and procedures