Health Information Management

Membership Update: Job description for denials management position

CDI Strategies, March 13, 2014

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Not to beat a dead cliché, but the old adage “garbage in, garbage out” is as true in CDI as elsewhere in the world. The “garbage out” portion often refers to the negative affect of physician documentation on healthcare quality scores and public reporting but it also refers to fiscal intermediaries’ and auditors’ claims’ denials. If a physician does not appropriately capture the reasons for admission, it may not matter how specific the rest of the documentation gets since the claim most likely will be denied.
Many CDI programs work with their denials management or auditing departments to identify which diagnoses are being denied and to review documentation improvement opportunities with an eye toward reducing those denials.
In fact, a recent ACDIS poll shows that 56% of 381 respondents review records with an eye toward Recovery Auditor defense. It’s an upward trend: Answering a similar question, “Is your CDI team involved in Recovery Audit reviews and/or denial management?” only 32% said yes back in April of 2012.
 
Part of the job description requires analysis of clinical documentation, evidenced based criteria application outcomes, and physician documentation, along with complete review of the medical record related to clinical denials. It also calls for identification and communication of denial trends, and collaborative processes to reduce denials overall.
Although denials management is a distinctly different role from that of the concurrent CDI specialist, members of the Forms & Tools Review Committee highlighted some of the overlapping skill sets required for two positions, while emphasizing that CDI specialists should not be asked to play a dual role.
Editor’s Note: Read more about the CDI role in audit defense in the following articles:

 



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