Clinical Documentation Improvement (CDI) Programs

on Tuesday, 01 June 2010. All News Items

In today’s healthcare climate, hospitals are facing increased scrutiny from outside agencies (i.e. MAC, RAC, CERT, ZPICs) that are focused on medical necessity, accurate coding and billing and detecting fraud and abuse.  On May 2, 2010 AHIMA released their Practice Brief titled “Guidance for Clinical Documentation Improvement Programs.” This brief indicates that “the most vital role of a CDI program is facilitating an accurate representation of healthcare services through complete and accurate reporting of diagnoses and procedures.”  Improvement in clinical documentation accuracy can support medical necessity, validate coding and billing and mitigate compliance risks.  

This brief goes on to discuss a CDI program’s policies and procedures, the role of a CDI professional, competencies for the CDI professional, potential CDI program staffing models, the role of the Physician Advisor in a CDI program and the Query Process.  

AHIMA also released a Clinical Documentation Tool Kit on April 29, 2010 that details what is needed to implement and/or maintain an effective CDI Program.

Both CDI resources can be accessed on the AHIMA website at www.ahima.org

Source: May 2, 2010 AHIMA Practice Brief – Guidance for Clinical Documentation Improvement Programs

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