Health Information Management

Tip: CDI programs find expanded role in ED documentation efforts

CDI Strategies, August 4, 2011

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JA Thomas expanded its CDI offerings to include the ED and other points of entry roughly two years ago, says Mel Tully, MSN, CCDS, senior vice president of clinical services and education for the consulting firm. The organization calls individuals who perform these roles “clinical integration specialists” as part of what it dubs its “Clintegris” program.

The ED clinical integration specialist receives typical CDI baseline education but is also trained and accredited in InterQual® criteria, medical necessity concerns, and patient status regulations. Although these tasks generally fall under the purview of ED case managers, implementation of the ED CDI role would shift responsibilities slightly, says Tully.
“The case manager is still there. The CDI [specialist] looks to the patient status [and other areas] as they touch the documentation piece. This allows the case manager to concentrate on their primary role, which is discharge disposition, helping the social work team, finding appropriate care options, and working with the patient and family regarding the patient care plan,” she says.
The ED CDI specialist would also look to identify present-on-admission conditions and the appropriate documentation/application of core measures. JA Thomas works with facilities to identify core measure scores “that are not where they should be,” says Tully, “like antibiotic choice for pneumonia.” Such a record review generally results in two positive outcomes: the CDI specialist captures the core measures and the documentation needed for increased specificity.
Editor’s Note: This article was excerpted from the July edition of the CDI Journal.

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