This is a very exciting time to be in the field of clinical documentation improvement (CDI), with so many emerging opportunities beyond just reviewing for major complications and comorbidities (MCCs) and complications and comorbidities (CCs). CDI programs are growing into so much more than just a mechanism for reviewing documentation for reimbursement purposes. Many CDI programs are now expanding their scope of work to include identifying opportunities for quality reporting and other secondary uses of health data.

As the Centers for Medicare & Medicaid Services (CMS) continues to refine Medicare quality indicators and other quality measures, it’s important to clarify what each CDI program does and define the program measures that accompany the quality component. Today, severity of illness is the common measure of CDI that most acutely affects severity. As CDI staff identify additional relationships and demonstrate a positive affect between CDI activities and quality outcomes, they should collect the appropriate data and report on the measures. An example of this is to define further the present-on-admission (POA) status of hospital-acquired conditions such as vascular catheter-associated infection. It is important for the provider to document if each infection was in fact, present on admission or if it developed after admission. A CDI query may be necessary to clarify the POA status further.

With these changes, the knowledge and skills set needed by CDI professionals is expanding to include not only clinical, coding, and communication skills, but also the ability to keep up with a multitude of quality, compliance, and regulatory initiatives. Along with this, many CDI programs are moving outside the walls of the traditional inpatient acute-care setting into other settings, such as hospital outpatient, physician offices, long-term care, and home health. The expansion into these other care settings brings along with it many new opportunities for improved documentation and more accurate reimbursement and quality reporting. 

The move to the outpatient setting, which includes emergency departments, ambulatory surgery, hospital outpatient, and physician clinics, brings with it a whole new realm of educational needs for the CDI professional. No longer is it only about principal and secondary diagnoses. Now the CDI professional must understand how the revenue cycle works in these different care settings and what drives reimbursement, such as quality reporting. Take, for instance, the CMS Physician Quality Reporting System (PQRS), which is a reporting program that encourages physicians and group practices to report on quality of care to Medicare using over 250 different measures. This program allows participating providers and group practices to assess the quality of care they provide to their patients to help ensure that patients get the right care at the right time. To take full advantage of this program, providers must have complete and accurate documentation. This presents the perfect opportunity for a CDI professional to advise on appropriate documentation, which in turn will benefit the quality of care being provided to the patient.

How do CDI programs (and professionals) make the transition from acute care to these other care settings? The first step is to identify what areas have potential documentation gaps and the need for higher-quality documentation. The main purpose of a CDI program is to ensure high-quality documentation, which results in accurate reimbursement for the facility/provider and quality care for the patient. The CDI program/professional should look for areas that would benefit from improved documentation practices. Internal audits, reviewing denial reports, and external audits are ways to identify areas that may need improvement. 

After a documentation need is identified in a specific care setting, then the CDI professional must seek training to understand the nuances of the revenue cycle and documentation practices at that particular care setting. For example, if a program is expanding to the physician clinic setting, the CDI professional(s) must understand CPT® coding, including evaluation and management codes, and the importance of medical necessity and knowledge of any quality initiatives in which the clinic is participating.

A CDI program in a physician office setting will be much different than the traditional acute-care CDI program in ways besides just the revenue cycle process and quality initiatives. The workflow also will need to be considered. In the acute-care setting, the CDI professional has the luxury of looking over a patient’s health record while the patient is still in the hospital and can discuss any documentation gaps with the physician in real time. In the clinic setting, the patients are in and out in minutes (not days), and it’s unlikely that the CDI professional will have the real-time interaction with the physician while the patient is in the clinic. Determining the best workflow for the providers and CDI professionals will be based on the individual setting and the dynamics.

High-quality, complete, precise documentation has so many positive results for physicians and facilities that extend beyond just reimbursement and the acute-care setting. Spread your wings and fly into this new era of CDI. The sky is the limit! 

Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer

Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, is senior director of HIM Practice Excellence for AHIMA. In her role she provides professional practice expertise to AHIMA members, the media and outside organizations on coding and clinical documentation improvement (CDI) practice issues. She authors material for and supports AHIMA online ICD-10 coding education platforms. She also serves as faculty for the AHIMA ICD-10-CM/PCS Academies and CDIP Exam Preps. In addition, Ms. Endicott is a technical advisor for the Association on ICD-10-CM/PCS, ICD-9-CM, CPT coding and CDI publications.

Latest from Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer

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