Health Information Management

Tip: Involve compliance officers/auditors in CDI program development

CDI Strategies, January 22, 2009

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With new physician query guidance released in September by the American Health Information Management Association (AHIMA), and expected scrutiny from recovery audit contractors on the way, now is the time to make sure your CDI team has the compliance training it needs. But many CDI departments remain insulated, which can be a recipe for trouble.
 
From veteran programs to new CDI initiatives, CDI department managers should seek their compliance officer’s assistance to target compliance training for specific CDI needs, says Andrei M. Costantino, MHA, CHC, CPC-H, CPC, director of organizational integrity at Trinity Health in Farmington Hill, MI.
 
Together, the compliance officer and CDI specialists should:
  • Develop a query policy based on the new AHIMA guidelines (regardless of whether your CDI program is in-house or consultant-based). This ensures a standard way of managing the query process, data integrity, and compliance.
  • Create an educational program based on the new AHIMA guidelines for physicians, CDS staff members, and coders.
  • Generate an auditing and monitoring process in collaboration with the compliance officer to ensure that your CDI staff members follow the query policy and that your queries do not incorrectly or unduly influence medical record documentation.



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