Practice Management Alert

Question: How can I make sure my nonclinical staff are trained, especially on crucial recordkeeping like clinical documentation integrity (CDI) — and that that their education is continuous? What should I be covering?

AAPC Forum Participant

Answer: Getting organized is the first step in preparing your staff adequately for any kind of onboarding or orientation or continuing education (CE). With so much information to navigate and learn, staff are really at an advantage when the educational materials are organized and presented clearly and concisely. Tamara Thivierge, MHA, CPC, recommends dividing CDI education into outpatient versus inpatient reviews (which may or may not make sense for your practice, depending on your patient demographics), and then preparing internal audit checklists.

Practices should put the work into developing resources for coding and CDI staff, including establishing and providing physical and digitally accessible handbooks that can serve as a go-to source for necessary information. She recommends making sure you include the kinds of things that coders and CDI staff need to know to do their jobs, regardless of experience: terms specific to your practice’s specialty, acronyms, pertinent regulations, electronic health record (EHR) templates, and so on. Don’t forget to bolster your handbooks with references like the Centers for Medicare & Medicaid’s (CMS) resources on documentation, so staff know where to go if they encounter a thorny issue or need more information.