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AHIMA Fuels Clinical Documentation Improvement with New Toolkits

Clinical documentation improvement toolkits on outpatient documentation and denials management can aid providers in strengthening patient care.

clinical documentation improvement ahima toolkits

Source: Thinkstock

By Elizabeth Snell

- Clinical documentation improvement (CDI) helps healthcare organizations capture meaningful data for improved quality reporting and clinician productivity. In an effort to ensure that the entire patient record is documented properly, AHIMA released two new CDI toolkits earlier this month to ensure data exchange is accurate and complete.

The two new toolkits focus on CDI on outpatient documentation and denials management to support the exchange of complete and accurate data across the care continuum.

AHIMA identified that it needed to work on a toolkit specifically for the outpatient environment, explained AHIMA HIM Practice Excellence Director Tammy Combs, RN, MSN, CDIP, CCS, CCDS. This is because CDI, which started in inpatient, is migrating out into the outpatient world.

“Now that they're starting that migration, they need some guidance in what that's going to look like,” Combs told EHRIntelligence.com. “That's what gave us the idea for the Outpatient CDI Toolkit.”

“We brought together experts from our CDI practice council, which is a group of volunteer experts that come together to participate in these projects,” she continued. “Other professionals were brought in as well, that specialize in the outpatient environment and clinical documentation improvement.”

READ MORE: Enhancing Patient Care with Clinical Documentation Improvement

The outpatient toolkit is meant to provide guidance to a CDI program that may be expanding into the outpatient environment, but that program may also have already started inpatient.

“Maybe it's an outpatient clinic that is independent from the inpatient setting, or maybe they're part of a hospital group and they want to ensure that their documentation is of highest quality,” Combs posited. “The toolkit comes together and has guidance for both of those outpatient structures.”

With the denials management toolkit, AHIMA wanted to focus on how denials management is impacting the world of CDI and coding. Whenever you think of CDI, you think of coding, Combs explained.

“They go hand in hand with each other,” she said. “CDI is looking for that accurate documentation to support accurate code assignment. And as denials-management teams are pulled together, we're hearing more out there in the industry that CDI and coding professionals are being brought into the denials process.”

“If a denied claim comes into an organization, they're wanting these subject-matter experts to review the documentation for those denied claims that are applicable to them,” Combs continued. “If missing documentation is the reason for the denied claim. They may have a CDI professional come in and review to determine if they agree with that finding or if they recommend an appeal for that denied claim.”

READ MORE: EHR Clinical Documentation Differs Between Nurses, Physicians

Coding can have a very similar process, she noted. Sometimes CDI and coding professionals can work together to look for the documentation and that code assignment to determine if they agree with the denial or if an appeal needs to be made.

Should an appeal need to happen, organizations may need to know what that process is like.

“That's where a lot of the confusion has come in,” Combs explained. “The denials team is bringing in CDI and coding. They're experts in their field, so they're good at reviewing those cases and identify if an appeal should be made. But then how do they go through that appeals process?”

The denials management toolkit will cover that entire process, including explaining what denied claims is all about, why they occur, how to identify if an appeal is warranted, and then how organizations can develop that concrete appeal letter.

As providers continue to rely more and more on coded data, documentation becomes even more critical, Combs stressed.

READ MORE: Healthcare Orgs Increasingly Value Information Governance

“You know the old saying: if it’s not documented, it didn’t occur,” she said. “Now everything that's documented in the health record, is translated out into either an ICD-10 CM, ICD-10- PCS, or CPT® code.”

“These codes are how providers are recognized on the quality of care that they've provided,” Combs added. “This also impacts their reimbursement. It tells the payer that's looking at these denied claims or researchers out there what diagnoses occurred. It helps determine the outcomes. If the documentation is not in place, then the accurate code cannot be assigned.”

It’s important for providers to be able to focus on quality patient care. CDI was created to help providers understand all of the dynamics, details, or verbiage that's needed within the documentation to support those code assignments. It essentially serves as the liaison between the physician and the coding professional.

“In medical school, providers are trained to take care of the patient, but they don't get a lot of training on what needs to be documented,” Combs stated. “They understand a high-level overview of what they need in that documentation.”

“Maybe they know that they need to document the type of heart failure, but if they don't know that they need to say if it's systolic or diastolic heart failure, rather than right-sided or left-sided heart failure, then they may not be capturing the true picture that's occurring,” she continued. “What type of heart failure has truly been treated?”

Understanding those elements within the documentation is where CDI comes in, Combs noted. It’s about reviewing that health record and identifying that maybe that type of heart failure has not been documented. From there, a compliant query can be sent to the provider to identify that type of heart failure.

Providers are the only ones who can diagnose, Combs maintained. CDI professionals are there to look for a gap in the documentation and then send a query, which is just a question asking if it can be clarified further.

Overcoming CDI challenges in inpatient, outpatient settings

With inpatient settings, CDI has been very successful, Combs said. The patient is in the hospital for a few days, and there is time to review the documentation while the provider is actually taking care of that patient.

It can be a challenge if the CDI professional does not get a chance to review the documentation during the admission and then the patient is discharged.

“Then you're reviewing it after the care has taken place, so you have to come and talk to the provider after they've already taken care of that patient,” Combs explained. “The provider is taking care of a new set of patients. It's hard to remember everything that occurred.”

CDI wants to have that concurrent review, or as close as possible to the time of the care actually being delivered.

This can also be an issue on the outpatient side, because whether in an emergency room or physician clinic, there is a lot of patient turnover. Having a process in place may look differently in that outpatient setting to ensure that documentation can be reviewed in a timely manner, Combs stated.

One potential way to overcome that issue is training medial scribes on CDI, she said. It would provide that real-time person to see what is being documented and look at the concurrent queries to see if there is a potential gap in documentation.

“In a wonderful world, if that scribe or the CDI professional is out there with the physician and they're elbow to elbow talking to each other, then that's great,” Combs suggested. “They can talk about any potential gaps in the documentation. But that's not always reality.”

Patients are seen in a fast-paced environment. Patients are always the number one priority, but how does a query fit into a physician’s workflow?

“What lots of CDI teams do – and what we recommend – is whenever they're setting up a process, inpatient or outpatient, to work with the providers,” Combs explained. “That way, whatever process is developed, it works within their workflow. Including the providers in the process can help a lot with that.”

Hesitation from the provider can also be an issue with CDI. If a provider has never worked with a CDI professional before, she may not understand the need for that higher level of specificity in her documentation.

“It’s important to provide education out to those provider groups so they understand what CDI is, why it's needed,” Combs said. “And then explain it's a resource for them to utilize, not a hindrance to them. It’s a resource to ensure that they get credit for the work that they're doing by validating that documentation is of high quality.”

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