Health Information Management

Strategy: Position your CDI role to meet the evolving world of healthcare reform

CDI Strategies, November 12, 2009

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With so much attention on healthcare reform and CMS’ shift toward paying for quality, CDI specialists should seek to align their unique role in healthcare with these new trends, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent consultant located in Madison, WI.
CDI specialists should review the medical record in its entirety, including the history and physical and the discharge summary, with an eye on ensuring proper documentation of not just reimbursement opportunities (i.e., CCs and MCCs), but medical necessity.
One neglected part of the record upon which CDI specialists can make an immediate impact is the discharge summary, Krauss says. This is often the only portion of the medical record that the next provider to whom the patient is discharged (e.g., home health or a skilled nursing facility) receives, and it often contains nonspecific diagnostic information.
So if a CDI specialist clarifies physician documentation of urosepsis or renal insufficiency elsewhere in the record, there’s no guarantee that the clarification will carry over to the discharge summary, which may cause denials for the hospital and the physician’s professional fees. “It doesn’t help in terms of reducing the supposed waste in healthcare due to readmissions if we don’t get the patient’s acuity properly documented and represented in the discharge summary,” Krauss says.
As always, Krauss advises CDI specialists against just looking for undocumented CCs and MCCs in the record. “We need to focus on all the diagnoses that impact acuity, not just buzzwords so that we can code something,” he says. “CDI program directors should seek to make their programs more business-like and carry a message of collaboration to the physicians.”

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