CDI Policy and Procedure

Purpose

To provide a standardized process of communicating with the medical staff and providers in order to achievecomplete and accurate documentation. Appropriate clinical documentation clarification requests will improve the accuracy, integrity, and quality of patient information in the health record. Clinical documentation clarification requests are an established mechanism for clarifying ambiguous, incomplete, unclear, or conflicting documentation in the health record.

Scope

University Hospital will implement this process in order to capture the most complete and accurate documentation for the services provided. This process is designed to capture documentation in the health record that is an accurate reflection of the:

  • Severity of illness/Risk of Mortality
  • Intensity of service/resource consumption
  • Length of stay
  • Treatment complexity
  • Diagnostic and procedural coding/DRG assignment
  • Appropriate reimbursement
  • Regulatory Compliance

It will also serve as a source for:

  • Data collection
  • Analysis and/or trending
  • Outcome measurement
  • Quality improvement

GOAL

Clinical documentation improvement will be accomplished through:

  • Identifying and clarifying missing, conflicting, or nonspecific physician documentation related to diagnoses and procedures.
  • Supporting accurate diagnostic and procedural coding, Diagnosis Related Group (DRG) assignment, severity of illness (SOI), and expected risk of mortality (ROM), leading to appropriate reimbursement.
  • Promoting health record completion during the patient’s course of care.
  • Improving communication between physicians and other members of the healthcare team.
  • Educating providers on the importance of concurrent documentation in the health record to achieve complete and accurate documentation.
  • Improving documentation to reflect quality and outcome scores.
  • Improving coders’ clinical knowledge.

Employee responsibilities

CDS employees are responsible for implementing these guidelines. It is the responsibility of the individual to implement, enforce, update, and ensure compliance with these guidelines.

DEFINITIONS

CDS professional-Clinical Documentation Specialist - an individual who reviews health records on a concurrent basis and aids the provider if opportunities to improve documentation are identified.

Clarification-to make clear or easier to understand (e.g., a needed clinical interpretation of a given diagnosis or condition based on treatment, evaluation, monitoring, and/or services provided; a needed agreement of diagnoses by other non-physician members of the healthcare team; a needed diagnosis for conflicts between attending and consulting physicians),

Coding professional- an individual who translates the descriptions of diseases, injuries, and procedures into numeric or alphanumeric designations for reimbursement, morbidity, clinical care, research,and education.

Concurrent – pre-discharge; patient is in-house.

Provider – any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis.

Post billing – post-discharge; after billing.

Retrospective – post -discharge; before billing.

Specification – a detailed description (e.g., documentation to more accurately reflect the acuity, severity, and the occurrence of events to represent an accurate and complete description of the patient’s clinical condition).

PROCEDURE/PROCESS FLOW

1)After midnight, obtain a hospital census with identifiers of :

a)Room number

b)Patient Name

c)Insurance Carrier

d)Date of admission

e)Physician name

f)Admitting Diagnosis

2) Each CDS professional will review patients’ health records duringtheir designated shift. When staffis limited, the CDS professional will begin by performing health record reviews with focused admit diagnoses and surgeries to review for complications.

3)The CDS professional will initiate a worksheet on new admissions, which should be placed in a designated section of the health record on the floor. Each worksheet will include:

a) Patient Name

b) Account Number

c) Admission Date

d) Working DRG

e) Procedures

f) Principal Diagnosis

g) Additional Diagnoses (that impact the DRG or severity of illness).

4)If a physician query opportunity is identified, the CDS professional should query the physician verbally, place a written query in the designated section of the health record with patient identifiers and CDS contact information, or submit the query electronically. A notation regarding the query, type of query (verbal, electronic, written), date and reason will be added to the worksheet. If no query opportunity is identified, the CDS will continue to review the patient health record for further query opportunitiesas per thereviewprocess.

(See separate hospital policy #______regarding physician query process).

5)The CDS professional will partner with the lead coder to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness and/or risk of mortality.

6) At the time of the patient discharge, the coder will assign a final DRG based on documentation in the health record, answered queries and official coding guidelines. Any discrepancies between the working DRG (CDS assignment) and the final DRG (coder assignment) will be discussed.

REPORTING

CDS provider communication should be tracked and trended to determine educational opportunities for providers based on the type, volume, and response to provider communication.

Consider developing a Case Mix Index (CMI) Report by Physician Group: this report will allow the CDS professional to review CMI for individual providers and their practices. Case mix index monitors potential fluctuations in provider severity of illness (SOI) and may identify those providers requiring additional documentation/coding education.

Generate a bi-annual Report of Secondary Diagnoses to monitor the number of patients, total and average number of secondary diagnoses per patient, and monitor extremes, outliers, and fluctuations in data.

EDUCATION

Face-to-face meetings: Propose to meet bi-annually with physician department chairs to review CDI data.

Educational Materials: Develop educational information for providers and place in strategic places throughout the hosptial.

Storyboards: Consider developing a CDI storyboard for hospital and medical staff to review.

Electronic: Educate providers through annual medical staff assessments.

QUERIES

See Hospital policy number ______.