Elements of a Successful CDI Program

People & Processes: Provider Engagement: System/Software: Monitoring & Management

  • Focus around Quality & Compliance: Approach and the processes are centered around rules and regulations. Accurately reflect the patient’s severity of illness and risk of mortality

  • Collaboration: Important to leverage clinical and coding expertise to reach the program’s objectives

  • Stakeholders: Engaged Executive Team that provides organizational support and participation

  • Medical Staff Engagement: Provide a clear understanding of the benefits to the providers along with ongoing education and feedback

  • Knowledge and Education: Provide an opportunity for staff to gain knowledge through a targeted educational program so staff can evolve and be successful

  • Technology: Effective technology along with tools and resources that promote an effective workflows and processes

  • Process Management and Feedback: Consistent feedback on the staff’s day to day processes with actionable information.

  • Outcome Measurement and Feedback: Consistent feedback on outcomes: Compliance, Quality, and Production falls under the Monitoring & Management component.

Compliance Risks

  • CDIS queries are formatted and submitted in a “leading manner”

  • Impassioned providers may agree to every CDIS query thus leading to incorrect diagnoses, leading to denials and or audit/investigation

  • Providers may take CDIS’s guidance and document certain conditions as likely, probable, and or possible without the clinical indicators supporting the diagnosis

  • Moving away from coding guidelines, evidence based practice, or ACDIS/AHIMA CDI practices that may lead to non-compliance

  • Influence from outside consulting resources or influences from internal forces that may lead to increasingly non-compliant practices

How an Successful CDI Program Mitigate Compliance Risk

  • All that matters is quality patient outcomes=how well the provider is treating the patient’s illness

  • If the provider is providing quality care and documents appropriately, far less likely to be at risk

  • A complete and accurate medical record that is reflective of the services rendered and reflects the acuity of the patient is the correct approach that will withstand an audit

The CDI Program can

  • Participate in capturing medical necessity for inpatient stays

  • Capture a reliable, complete, and accurate medical record

  • Assist in identifying accounts to be reviewed as part of OIG Initiative Topics

Opportunities for Collaboration with Compliance & CDI

  • Get involved in CDI development

  • Understand AHIMA and ACDIS Guidelines & Code of Ethics

  • Knowledge of AHIMA Guidelines for Achieving a Compliant Query Process

  • Provide compliance education to key CDI stakeholders-target compliance training for specific CDI needs

  • Champion guidance and reviews on all queries (including verbal query guidelines)

  • Bridge CDI, HIM, and Quality Collaboration

  • HAC reviews



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