Health Information Management

Tip: Track basic data to prove CDI program value

CDI Strategies, August 20, 2009

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In establishing a CDI program you’ll want to keep a number of items in mind, says Margi Brown RHIA, CCS, CCS-P, CPC, CCDS, director, Precyse Solutions, LLC, Wayne, PA. Once you have the structure in place you’ll need to figure out what elemental data to track to prove your program’s success.
 
To determine the overall “value” of the CDI project, says Brown, you need to capture and measure the number of charts reviewed in relationship to the number of discharges per month (percentage of discharges reviewed); the percentage of physician interactions (queries) per number of charts reviewed (percentage of queries); the percentage of charts reviewed and how many reviews were done per number of discharges per reviewer (individual reviewer productivity).
 
Consider capturing other basic types of information such as the name of the reviewer, the dates he or she reviewed a particular cases and the number of times he/she reviewed that case compared to the number of times other cases in the queue received reviews. Tracking patient data such as account numbers, admission information, and attending physician are an important part of CDI work as is keeping tabs on the patient’s working DRG and the working principal diagnosis.
 
CDI program administrators also need to track information related to the query process. Track the query date, topic/subject, and the physician response whether the physician agreed, disagreed, left an incomplete answer, or provided no response at all.
 
Lastly, make sure to track patient discharge information such as the date of discharge, length of stay, final DRG, reconciliation comments, and any additional applicable comments.
 
Editor’s note: Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS, recently joined Precyse Solutions working with the team directors of Clinical Documentation Improvement, education, auditing, Recovery Audit Contractors (RAC), and business development. Contact her at mbrown@precysesolutions.com.



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