Title: Module 2 Instructions
Course: HIM 3620 - TAACCCT Grant > Section: Module 2 - Types of Clinical Documentation

Readings

- Chapter 2
- Appendix E, p 189 "Getting Quality Clinical and Coded Data: How UMHS's CDIP Improved Clinical Coded Data and Clinical Staff Relationships"
- Article: "Hiring a CDI Specialist: 3 tips you need to know" written by Kayce Dover.

Lecture

One of the best teams I worked on was with a RN and I running the Utilization Management department for a large hospital. We both brought strengths to the table which made us a good team. Whether you are a RN, RHIA, or another Allied Health Professional we all bring strengths to the CDI team. Who professionals make up your CDI team? What about the medical staff director or other physicians? Are they part of your CDI team? What is their role in the CDI team? Ch 3 discusses the importance of coding in CDI. Notice the methodology for query physicians? How is your query process set up at your facility?

One term discussed that I want to reiterate in Ch 3 is  present on admission. POA (Present on Admission) is another important item that needs to be clarified in the health record. It is imperative that pre-existing conditions that may potentially cause increased care or utilization of resources be documented as being present at the time of admission.  Failure to specify pre-existing conditions such as decubitus ulcers, pneumonia or a urinary tract infection due to an indwelling foley catheter, could potentially result in a decrease in payment for the hospital. Decubitus ulcers and pneumonia are MCCs (major complications and co-morbidities) and if are not specified as having been present on admission but have the appearance of having occurred following admission, could potentially impact the MS-DRG that is allowed to be billed.

This is just another example of the impact of documentation for facilities. As the rules change regarding reimbursement, so does the need for more in-depth and complete documentation by physicians.

In the CDI role you must be willing to speak to the physicians directly. Speaking to a physician or a group of physicians can be a daunting task. They  must be educated and informed to be sure that they are able to perform their documentation requirements as completely as possible to avoid needing to “touch” the chart again at a later date. The CDI needs to learn the best way to approach the practitioner that she will be working with and this approach can vary depending on the practitioner. The CDI will need to find the method that works best for her and conveys the information to the physicians in a direct, fact-based method that most doctors seem to prefer.

A good approach is to be sure to not have the question come across to the physician as though the CDI is questioning that practitioner's skill or decision making, but rather in a manner illustrating your need for clarification in what he has already written. Be sure to give the physician clear explanations as to what specificity is needed in order to provide the most complete documentation.  The CDI/physician relationship is an important one that needs to be cultivated in such a way that the physician has “buy-in” to the Clinical Documentation Improvement Program and through this, the CDI gains credibility with the physician.

Remember that this is a partnership. What is specific in the physician’s “clinical world” may not be specific enough for the “coding world”.

Assignment

Review the sample job description and cover letter in the module. Find a CDI position available or CDI job description. Write a cover letter expressing interest for this position. Include information from your resume and also topics from Chapters 1 and 2.