At the center of health care today is the need to provide guidance through a sea of regulations and fraud, ultimately assuring accuracy in health information. Clinical documentation improvement (CDI) is the bridge that connects clinical care providers to both coding professions and external resources to ensure accurate quality reports.
A newly updated AHIMA CDI Toolkit for HIM professionals offers guidance on developing and maintaining a structured program. It also reflects recent changes in documentation requirements and ways to measure success in CDI programs.
"Clinical documentation improvement programs are the center of health care today, as they serve as a crucial map to guide accurate, timely and consistent information," says AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA. "The transition to ICD-10 has intensified the need for this high-quality clinical documentation, but such results cannot be achieved without a structured program. With this toolkit, AHIMA provides the necessary tools and documents needed for ensuring a robust CDI program."
Updated topics in the 2016 revision of AHIMA's CDI toolkit include the following:
• changes in documentation requirements and approval procedures;
• metrics for analyzing data to determine the success of the program;
• the role and benefits of the physician advisor in CDI;
• how to hire the right individuals to start a CDI program; and
• revised information regarding the use of secondary coded data and how it affects quality measures and third party audits.
The toolkit also includes several appendices to further improve CDI program implementation and hiring, including the following:
• sample job descriptions;
• a checklist for CDI orientation training;
• a sample 90-day evaluation form;
• key monthly metric reports and graphs; and
• query or clarification monitoring samples.
The toolkit is free for AHIMA members and can be found online in AHIMA's HIM Body of Knowledge and on AHIMA's web store.