Clinical documentation improvement (CDI) are three buzz words in today's healthcare lingo that have come to signify a means of achieving better data quality that leads to more accurate reimbursement and perhaps even better patient care.
Most of the sources with whom I've spoken—including coders, nurses, and even physicians—advocate for the CDI efforts. However, one danger of such a program is that hospitals must ensure safeguards to prevent leading physicians down the long and winding path to a diagnosis.
Having a CDI program doesn't negate the fact that physicians must continue to maintain their authority in providing a diagnosis. And therein lays the conundrum for many hospitals: How to obtain this much-needed information without leading docs in the process.
Verbal queries, in particular, have remained a source of contention for hospitals simply because they are difficult to audit and monitor. Coders and CDI specialists know that they aren't supposed to lead physicians to a diagnosis, yet when questions are posed verbally, there is a significant risk that this will take place during course of conversation meant clarify documentation.
Hospitals need to specify—in their policies and procedures—why a coder or CDI specialist will initiate a verbal query as well as what the content of that verbal query will include. Consider adding the following language:
The clinical documentation specialist may have a discussion about a patient with a physician. This discussion will be an opportunity to educate the physician and to obtain specificity in the documentation. The clinical documentation specialist may discuss the clinical findings and documentation with the physicians involved in the care of the patient. The role of the clinical documentation specialist is to educate the physician on the specificity of verbiage which can result in improved capture of severity of illness. In addition, the clinical documentation specialist will pose verbal queries (questions) to the physicians so that clarification may be documented.
"I think having a policy in place that outlines the role of the CDI specialist and the parameters of the verbal queries will protect your organization if ever there is an outside review of your charts," says Melissa Ferron, RHIA, CCS, president, Melissa Ferron Healthcare Consulting, LLC.