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Clinical Documentation Improvement Program

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Physician Program Overview
Our CDI program works to ensure the documentation in the medical record captures the true acuity of our patients. Accurate documentation will reflect appropriate severity of illness and risk of mortality to support resource intensity and length of stay for our patients.If a CDI nurse recognizes the need for additional documentation, a question (query) will be presented to you. This packet is intended to give you a little more information behind the program.
Take Away:Greatest level of specificity supports additional length of stay and increased resources required to care for the higher acuity patient
Medicare Guidelines dictatespecific words that must be present in order to choose and apply a code for billing. It is all aboutspecificity.Coders are not clinical and therefore not permitted to assume, infer or interpret data to arrive at a diagnosis.CDI Nurses perform a concurrent review of the medical record. Analyzing and comparing current physician documentation to clinical indicators and treatment. This information is applied to coding guidelines to determine if current documentation supports coding of accurate patient severity at this point in time.If inconsistent, missing or conflicting documentation is identified, a physician query or clarification question is posed to the physician.A prompt response is necessary to get this documentation into the record prior to discharge.
Please clarify documentation as requested, when appropriate, andinclude this diagnosis in your progress notes and discharge summary.Prompt response to the queryto get the documentation into the record and avoidthe necessity of apost discharge query.Aquery/question posed to the physician does not suggest or require a positive response.As always please exercise your independent professional judgment in responding to the query.Physicians cannot be expected to know all the coding and documentation guidelines as they change too frequently.Know that the Clinical Documentation Specialist is working diligently to capture accurate patient severity for physician profiling and at the same time provide resource consumption accountability for the sustainability of our hospital.
CDI Nurse role:

Physician role:

Query Process
The physician is alerted of aqueryin SAC within the signaturemanager as an incomplete document when you log into SAC.Open the document, which willdescribe the clarification of documentation that is requested.Review, modify and save your response.If unable to answer at that time, close and return when able to determine.Questionsor unclear of what to do contact the CDI nurse listed on the query.Sample cases to show how documentation clarification impacts your severity of illness (SOI), risk of mortality (ROM) and expected LOS (GMLOS)to follow.
Impact:Increased Severity weight providing for 8 more days for needed treatment and resources
Specificity : Specificity of anemia and diagnosis to support resource use
Specificity for : Sepsis due to UTI and Toxic Metabolic Encephalopathy
Impact:Increased severity weight providing for 8 more days for needed treatment and resources
Impact:Increased Severity weight providing for 3 more days for needed treatment and resources
Specificity : Type of Pneumonia and Severity of Malnutrition

Thank you for taking time to review our program information.
If you have questions or need additional information please contact one of our team:CDI Specialists:Vicki Byrd, LPN283-2137Debra Roth,RN283-2632LauraSteffey, RN283-2137Jan Hardy,RN283-2632CDI ManagerLisa Strother, RN 283-2358Medical DirectorWilliam Templeton,MD283-2777





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Clinical Documentation Improvement Program