7th Annual Association for Clinical Documentation Improvement Specialists Conference

Transcription

1 7th Annual Association for Clinical Documentation Improvement Specialists Conference CDI for the Newcomer Nancy A. Entwistle, MPA, RHIT, CCDS, CCS, ACE, AHIMA-Approved ICD-10-CM/PCS Trainer Manager, Documentation Improvement and Clinical Coding Emerson Hospital Concord, Mass. 2

2 Learning Objectives At the completion of this educational activity, the learner will be able to: Define the CDI role Use CDI competencies as a basis for orientation/education to the CDI role Develop written policies and procedures to establish standards for CDI practices 3 Definition of the CDI Role Purpose of the CDI roles in hospitals Medicare vs. all-payer reviews? Reviewing inpatient only? Surgical day? Radiology? ED OB/GYN yet? 4

3 Definition of the CDI Role Benefits of the roles in terms of protecting the integrity of physician documentation against CMS denial and/or RAC Are you expected to be involved with audit denials/findings/solutions? 5 Who Should Be a CDI? Nurses only? Coders with strong clinical background? A mix of both? Should they be required to have credentials? 6

4 What You Should Know Know the key stakeholders in your organization to identify support for the program CFO/CMO Care management Physician advisors? Understand your program mission Do you have one? 7 What You Should Know Shadowing of the coders that you will most closely work with to observe what specifics they are looking for from a coding perspective establish how open communication and effective collaboration can occur among two roles Understand the query process 8

5 Orientation to CDI Orientation should include boot camp Shadowing of other CDIs in your organization and potentially in other hospitals where an established successful program is present Official training on any computerized coding system used by the organization as well as any EHR used by the hospital 9 Building Relationships Meet with key stakeholders including department heads, nursing managers, quality, CFO Introduce yourself to your stakeholders Be a face of the program Be a contact or resource offer assistance to achieve goals 10

6 Evaluation Request a physician advisor (if you do not have one) Able to have medical and surgical advisor? Find weaknesses and recommend areas of assistance Determine communication methods that will be most successful 11 CDI Competencies (per the AHIMA Guidance for CDI Programs) Key skills and competencies for those in CDI roles include: Knowledge of coding concepts and guidelines and clinical terminology Ability to read and analyze all information in a patient s health record Clinical knowledge (anatomy and physiology, pathophysiology, and pharmacology) Ability to establish and maintain strong verbal and written communication with providers and other clinicians Knowledge of healthcare regulations, including reimbursement and documentation requirements 12

7 Follow Up on Progress Once program is up and running, establish a routine schedule of meeting with different services to provide updates on education Share findings with stakeholders Monthly CDI/coding meetings to review coding clinics, case studies, feedback, etc. 13 Education of Physicians Know your material first!!! Identify how physicians want to be educated Identify how physicians want to be communicated with Biweekly to monthly education bullets on different diagnoses in visible physician workstations, lounge, etc. 14

8 Physician Collaboration Collaborate with the physician advisor on how to effectively provide feedback and tips s/bulletins/notifications to communicate new material Survey staff for best method of communication vs. written vs. verbal 15 Continuing Education Become an active member of ACDIS, which provides access to: Blogs, CDI journal, e-newsletter, helpful resources Become an active member of your local CDIS state chapter if present Networking with others in your state Video conferences Excellent way to keep up to date without leaving your facility CDI certification Recognition of skills in clinical documentation Promotes the integrity of the medical record Read, read, and then read some more CDI Boot Camp materials, ICD-9-CM Official Guidelines for Coding and Reporting, effective October 1,

9 Important to Start Off Right Develop written policies & procedures to establish expectations and standards Ensure consistent CDI practices utilize resources for guidance (AHIMA, ACDIS) Define other elements: Compliant query practices Indications of when to query making it count vs. nitpicking Process number of reviews vs. re-reviews, when to consult a physician Resolution of your review follow up after discharge Background of individuals who do queries clinical background, coding background, a mix of both 17 Develop Benchmarking Criteria Develop criteria that will fit your institution based on bed size, types of cases to be reviewed, number of CDIs on staff, and services provided by hospital Meet monthly with physician advisor(s) to review physician compliance with queries and review CMI Results will guide what additional education may be needed Educate physicians in small groups, based on specialty or identified issue 18

10 References ACDIS 2010 CDI Program Benchmarking Survey ACDIS 2013 Physician Query Benchmarking Survey AHIMA 2010 Guidance for Clinical Documentation Improvement Programs ents/ahima/bok1_ hcsp?ddocname=bok1_ #AppxB 19 Thank you. Questions? In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the workbook. 20