Hint: Have written policies and procedures. During the 2021 RISKCON session, “Establishing an Effective CDI Program,” instructor Amy C. Pritchett, AAPC Fellow, BSHA, CCS, CPC, CPC-I, CANPC, CPMA, CASCC, CDEO, CRC, CMPM, CMRS, CEDC, C-AHI, gave helpful tips you can apply to establish a strong clinical documentation improvement (CDI) program in your cardiology practice. For example, she shared specific rules you should follow as well as measurements and metrics you can use. Follow these helpful tips to build your successful CDI program today. Tip 1: Pay Attention to Specific Components of Strong CDI Program The golden rule of coding is that if it is not documented by the physician or provider, it didn’t happen, Pritchett said. Documentation has never been as important as it is in today’s facilities and physicians’ offices. Documentation is critical for painting a picture for insurance and CDI alike about the patient during an encounter. Certain factors will drive an effective CDI program, according to Pritchett. They are as follows:
Tip 2: Keep 5 Vital Rules in Mind for Your CDI Program You should follow these specific rules when comes to your CDI program, Pritchett said: Rule 1: Providers should always be involved in your CDI program from beginning to end. Rule 2: Have skills on your team that range from clinical expertise to coding expertise. Rule 3: Follow the Association of Clinical Documentation Integrity Specialists (ACDIS), American Health Information Management (AHIMA), and Practice Brief updates. Rule 4: Maintain regular reviews by nonbiased experts such as physicians, clinical staff, coders, billers, and admin staff who are not part of your CDI team. “This does two things,” Pritchett said. “It gives you a fresh perspective on your CDI team and makes sure that peer review is going on and those queries are actually being legitimately posed to the physician.” Rule 5: Have written policies and procedures, which is a really important step, according to Pritchett. “Policies and procedures indicate when and why to query a physician,” Pritchett said. “For example, I have seen in my career all sepsis encounters on hold for the physician’s query. All sepsis claims. This is not proactive.” As a coder you should not have to code the chart then place it on hold for CDI review retrospectively, Pritchett added. Instead, for effective CDI, you should be working with the physician during the patient encounter for clarity, concise documentation, and the underlying condition documentation. “I’ve also seen cases where the physician was non-specific on sepsis, the laboratory results were positive while the patient was in house, and it’s still not documented,” Pritchett said. “This is really important because not only is sepsis categorized by the type of infection or ‘due to a bacterium,’ but also unspecified codes are bad and frowned upon by Medicare, Medicaid, and most commercial payers.” Tip 3: Successfully Query Physicians Pritchett also discussed when you should query your physicians and how to query the right way. Reasons you should query your physician include the following: When to query your physician: Querying usually occurs during the health information management (HIM) coding process, according to Pritchett. Three different types of queries include the following: When it comes to querying, you must make sure that you are not leading your provider, Pritchett cautioned. Leading is defined as implying there is an expected answer to your question or providing the expected answer to your question. Questions to ask when querying your provider: When you query your provider you should ask yourself the following questions, Pritchett said: Tip 4: Employ CDI Metrics You can measure different aspects of your CDI program, Pritchett said. Measurements and metrics include the following: Editor’s note: Want more great coding info like this? You can register for the upcoming educational events here: https://www.aapc.com/resources/events.aspx.