Health Information Management

AHIMA releases ethics guidance for CDI professionals

CDI Strategies, November 11, 2010

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In the spring, AHIMA released its “Guidance for Clinical Documentation Improvement Programs” in the Journal of AHIMA and also published its 41-page Clinical Documentation Improvement Toolkit. The documents offer sample job descriptions, definitions for documentation clarifications, sample queries, and guidance for how to measure CDI program success.

In the fall, AHIMA released its Ethical Standards for Clinical Documentation Improvement (CDI) Professionals which it says “are intended to assist in decision-making processes and actions, outline expectations for making ethical decisions in the workplace, and demonstrate the professionals’ commitment to integrity.” It also suggests that its standards apply to all CDI professionals regardless of whether they are AHIMA members or non-members.
“I really like that these standards apply to everyone who works in CDI,” says William E. Haik, MD, FCCP, director of DRG Review, Inc., in Fort Walton Beach, FL, who served on the committee which helped create the Ethical Standards. “It’s not just HIM folks, it’s not just CDI folks, and it’s not just physician advisors who need to follow these standards. What this says is that anyone who is involved in documentation improvement efforts needs to follow the Ethical Standards regardless of who is doing the job.”
The Ethical Standards includes nine elements which range in specifics from item number four which reads:
“Refuse to participate in or support documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or distort data by means that do not comply with federal and state statutes, regulations and official rules and guidelines.”
To item number nine which states that CDI specialists should:
Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal reporting practices, and fosters trust in professional activities.
“I really like that statement,” says Haik, “because it really illustrates that you shouldn’t get bullied by the financial types. There are many people who feel they essentially have to do what the corporate office tells them to do. This standard says that those performing documentation improvement need to stand up for what’s right.”
“Personally I agree totally with the document and think it provides ‘a gold standard’ for people to aim for,” says Lynne Spryszak, RN, CCDS, CPC-A, CDI education director for HCPro Inc., in Marblehead, MA. 
Each of the nine elements in the Ethical Standards further explains how CDI staff should read and interpret the main ethical points. For example, item number four includes two sub-categories which states that:
“Clinical documentation improvement professionals shall:
4.1. Facilitate documentation that supports reporting of diagnoses and procedures such that the organization receives the optimal payment to which the facility is legally entitled, remembering that it is unethical and illegal to increase payment by means that contradict regulatory guidelines.
Clinical documentation improvement professionals shall not:
4.2. Misrepresent the patient's clinical picture through intentional incorrect documentation or omission of diagnoses or procedures, or the addition of unsupported diagnoses or procedures to inappropriately increase reimbursement, justify medical necessity, improve publicly reported data, or qualify for insurance policy coverage benefits.”
All the recent CDI-related AHIMA publications have been the result of more than a year’s worth of work by a collaboration of nearly two dozen professionals, including four ACDIS Advisory Board members. AHIMA also cited a number of references as having influenced the creation of its Ethical Standards including both the AHIMA and ACDIS Codes of Ethics. 
Editor's note: Look for more analysis of the AHIMA Ethics Standards in the January editon of the CDI Journal.

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