By Patty Buttner

Clinical documentation improvement (CDI) ensures a true clinical “story” is captured in the health record by improving the integrity of healthcare data and providing a clearer representation of the care and services provided by an organization, and its impact on the health of the population. Over the past few decades, CDI has grown and evolved as healthcare leadership recognized that accurate data in both inpatient and outpatient settings is vital to organizational success. Healthcare data is not only used for reimbursement purposes, but for strategic planning, population health data, patient outcomes and quality of care, as well as a host of other uses.

Recommended best practices to guide the CDI process include:

Focus on the integrity of the health record
Coding professionals rely on accurate healthcare information in order to assign diagnosis and procedure codes to reflect the entire patient picture in numeric and/or alphanumeric codes. These codes are then used for reimbursement, regulatory compliance, accreditation and several other purposes. It is imperative that these codes are accurate and a CDI program can help ensure accuracy.

Involve staff from a variety of disciplines
CDI professionals may come from various backgrounds, such as health information management (HIM), nursing, and physician practices. Each discipline brings with it a unique set of skills to enhance the role. There is fundamental knowledge that must be known or learned in order to succeed in the role as a CDI professional as they proceed through the record review process and establishment of diagnosis and/or procedure codes, as well as communication with various healthcare professionals.

Knowledge and skills needed include:
• An understanding of anatomy and physiology
• Knowledge of pathophysiology
• ICD-10-CM, ICD-10-PCS, CPT and HCPCS coding
• Effective communication skills
• Excellent critical thinking skills

The query process
CDI professionals review the health record documentation to determine if it accurately reflects the health status of the patient, the resources utilized to care for and treat that patient and if this information can be translated into coded data. During the review they may discover opportunities to obtain clarification from the provider.

The common tool utilized by CDI professionals is the provider query. This tool is the main communication tool when the CDI professional identifies a query opportunity. There are best practices for when a query is indicated; the following list includes examples of when it may be appropriate to query the provider.
• When there are clinical indicators of a diagnosis but there is not documentation of a condition to coincide with those indicators
• There is clinical evidence for a higher degree of specificity or severity of an illness
• There is uncertainty of a cause-and-effect relationship between two conditions or organisms
• When clarification is needed for an underlying cause of symptoms
• Treatment is documented without a corresponding diagnosis
• Clarification if a condition was present on admission (POA)
• A diagnosis is documented without any clinical indications in the patient record
• There may be instances where a query is needed due to lack of completeness, inconsistent documentation or clarification is needed

Queries as noted above may be presented as verbal, written, or electronic. Best practices for the information contained within the query include: stating clearly and concisely why the query is being presented; the clinical indicators, medical evidence, or supporting data present in the health record which prompted the query; and the named CDI professional presenting the query. The impact on reimbursement or quality measures should not be included in the query.

Implement a clinical validation process
Clinical validation is a growing segment of CDI practices. There may be occasion when a diagnosis documented within the health record does not appear to be supported by the clinical evidence within the health record. This is where the clinical validation query comes into play. The updated AHIMA practice brief, “Clinical Validation: The Next Level of CDI”, which will also be addressed at AHIMA’s CDI Summit in July, explains that the clinical validation query is to “identify potential gaps in the clinical picture and send queries to clarify.” The provider is responsible for the establishment of all diagnoses and may be queried when there are gaps between the clinical evidence in the health record and documented diagnoses.

Create clear written policies and procedures
It is crucial for an organization to develop policies and procedures for all CDI related processes. Policies and procedures clearly outline the duties, processes and expectations of CDI activities and those departments and individuals involved. This ensures standardization and defines the roles and responsibilities as well as organization specific policies. Examples of policies and procedures include:
• CDI onboarding: This should include all CDI practices, workflow and expectations
• Query policies: This should include when, how and what to base a query on
• Escalation policy: This is an essential policy to ensure unanswered queries and other issues have documentation of the proper channels to follow

Involve a physician advisor
The role of a physician advisor, or champion, is highly recommended. This role is the bridge between the CDI team and the medical staff. This role can assist with the education process and physician engagement. If the physicians are not engaged and educated on the importance of CDI, there may be issues with physician responsiveness to queries.

About the author: Patty Buttner, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS, CICA, is the AHIMA director for HIM practice excellence.