Health Information Management

Associate Director’s Note: CDI ethics and best practices

CDI Strategies, April 30, 2015

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When was the last time you reviewed ACDIS/AHIMA’s “Guidelines for Achieving a Compliant Query Practice?” If it been more than a few months, consider taking another look. In recent weeks, a number of ACDIS members messaged us regarding potentially non-compliant query and CDI practices. Out in the field at local chapter networking events, participants often discuss query practices and frequently ponder which practices skirt the non-leading query line.

ACDIS representatives participated in creation of a number of AHIMA’s query best practice recommendations, but the latest version provides definitive practices around what constitutes “leading” and outlines several acceptable methods for querying.

Nevertheless the question of behaving ethically within the CDI realm bears further examination. While both ACDIS and AHIMA maintain codes of ethics (read our official Code of Ethics), more needs to be done to educate ourselves on appropriate behavior and conducting the daily business of record review in a compliant manner, particularly in light of ever changing reimbursement methods and medical record types (i.e., paper versus electronic records, computer assisted coding, and natural language processing for physician documentation).

To that end, ACDIS Advisory Board members Michelle McCormack RN, BSN, CCDS, CRCR and Mark LeBlanc, RN, MBA, CCDS, are seeking input from ACDIS members and CDI professionals regarding their experiences with ethical practices and compliant physician query practices. Please take a moment to complete this brief survey and help us identify topics to update our code of ethics. Your responses will remain anonymous and will be used to advance our practice guidelines. 



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