Health Information Management

Improve documentation with strong CDI specialist, program

HIM-HIPAA Insider, August 11, 2009

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By now, most coders are aware that ICD-10 will usher in expanded codes that will require additional specificity and more detailed documentation. A single diagnosis or procedure code in ICD-9-CM may be expanded to multiple codes in ICD-10-CM or PCS.

More hospitals will likely develop clinical documentation improvement (CDI) programs as ICD-10 takes center stage. Those programs that are already in place will likely need to grow, expand, and mature, says Heather Taillon, RHIA, manager of coding compliance at St. Francis Hospital in Beech Grove, IN, and a board member of HCPro, Inc.’s Association for Clinical Documentation Improvement Specialists (ACDIS). CDI programs will become commonplace, Taillon says, adding that this is something she’s already seeing on a national level.

Editor’s note: For more information about CDI programs and to purchase a copy of this article for $10, visit the HCPro Web site. Subscribers to Briefings on Coding Compliance Strategies have access to this article in the August issue.



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