Health Information Management

Tip: Consider expanding CDI to outpatient departments

APCs Insider, October 31, 2014

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An outpatient clinical documentation improvement (CDI) program should be aligned with a facility's ICD-10-CM initiatives, since both require a focus on coding and documentation. Payers may also be changing their policies regarding ICD-10-CM, which could require reporting much more accurate diagnoses.
For example, while current documentation for reporting asthma in ICD-9-CM may be sufficient, ICD-10-CM requires physicians to document terms such as "mild intermittent," "exacerbation," or "with status asthmaticus" in order for coders to report the most specific code. An outpatient CDI specialist will be able to look for those terms and query physicians when they are not included.
This tip is adapted from “Consider expanding CDI to outpatient departments” in the November issue of Briefings on APCs.

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