Health Information Management

Tip of the week: Incorporate coders into your concurrent documentation improvement program

HIM-HIPAA Insider, September 11, 2007

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The fundamental focus of a concurrent documentation improvement (CDI) program is to work with physicians to help them improve their medical record documentation. Ideally, this improved documentation will bridge the gap between clinical terminology, which is constantly evolving, and ICD-9 language, which tends to be stagnant and fixed in nature. Hold coders accountable for taking the initiative to learn more about the clinical aspects of coding. Although a coding supervisor may focus on productivity-rather than data quality-this individual must understand the importance of involving coders in the CDI process. This is the only way that coders will, in turn, understand the importance of CDI. Going forward, coders should make a conscious effort to take the following steps:

  • Review the entire medical record to gain an understanding of the complete clinical picture
  • Assimilate all of the information that the physician provides
  • Translate the medical record documentation into accurate ICD-9 codes that best reflect the patient's true severity of illness and overall acuity level

Editor's note: This tip was adapted from a recent issue of JustCoding.com. For more information, click here.



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