Clinical Documentation Improvement Will Benefit the HIM Department

Vol. 13 •Issue 11 • Page 14
Coding Outlook

Clinical Documentation Improvement Will Benefit the HIM Department

A clinical documentation improvement (CDI) initiative focuses on improving the documentation at the point of service. There are several different models that can be utilized and are usually based on the needs and culture of your facility. However, if you work in the health information management (HIM) department, you probably have a keen interest in deciding how a documentation improvement initiative unfolds at your hospital and how it will affect your department’s operations.


The main focus of CDI is to improve clinical documentation concurrently or at the point of service to the patient. This means that physicians and other clinicians should be queried or questioned about unclear or incomplete documentation while the patient is still an inpatient. Again, depending on the needs of your facility, this could be completed by a case manager, documentation specialist, hospitalist or even a concurrent coder. Don’t panic — the staff responsible for querying the physicians should at-tend education sessions to learn about documentation guidelines. They are trained and become familiar with the DRG system, complications and co- morbidities, principal diagnoses and other factors that can impact DRG assignment. The result is that when the medical record is sent to the HIM department after discharge, the physician has already been asked to clarify his documentation, if appropriate. Therefore, when the coding professionals are reading through the progress notes and other portions of the chart for coding purposes, they most likely will have everything they need to code and finalize the case for billing.

Sounds simple, right? In the real world, however, we know that a chart generally does not arrive in the HIM department in such a condition. CDI is a very positive step for a facility, and the HIM department will be able to see many positive benefits such as:

•Complete documentation available at the time of discharge

•Ability to process and bill charts more timely

•Decrease in physician deficiencies

•Increase in coder productivity

•Improvement in coding accuracy

•Improvement in hospital comparative data

•Improvement in hospital case mix index.



With CDI, there may be a decrease in the amount of deficiencies related to queries or incomplete documentation needed after discharge. Because Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards require charts to be completed within 30 days of discharge, queries tracked as a deficiency may increase your delinquency rate if not completed within 30 days. Querying physicians after discharge may also cause delays in billing for the patient’s stay. If a physician does not complete his/her charts on a regular basis, accounts may remain unbilled for 30 or more days. This delay may have an impact on the discharged not final billed accounts and the number of accounts receivable days. Before implementing a CDI program, the HIM director and patient accounting director should develop a strategy to manage the number of unbilled accounts due to unanswered physician queries.


Delays in physician queries also may create issues for facilities when cases are selected for committee reviews based on the ICD-9-CM codes or DRG assignment. If the cases are not coded or finalized before the scheduled medical staff or quality improvement meeting, it may be missed or omitted from review. This can become a quality of care issue, as well as an accreditation issue. For instance, in some states the UB-92 data is submitted to state agencies 30 days after the close of the previous quarter. If the cases are not coded prior to this data submission, the hospital will appear deficient when state reports are being processed. This data is then translated into publicly available comparative reports that are hospital and physician specific. Therefore, if documentation is incomplete or missing, the outcomes of these reports may not be favorable to the facility.


This need to query physicians can also create a productivity issue for your coding staff. Nonproductive time spent by coders to monitor record completion, such as did the physician dictate reports (discharge summary, operative report, etc.), did the physician respond to a query, was the response appropriate, does the response need further clarification, and even to recode and finalize the chart, is an issue. This is an important area to consider when determining coder productivity and staffing levels. If you frequently have incomplete clinical documentation that needs clarification, it may appear that your coders’ productivity has decreased even though that is not the case.


Reimbursement to a facility will also be a benefit of improved documentation. As mentioned earlier, with clarification being obtained from the physician while the patient is in-house, the coders will be able to assign the most specific codes. This will help the hospital tremendously in that the collection of secondary conditions, that are traditional complications and comorbidities, will be increased and yield higher reimbursement to the hospital. In turn, the hospital’s CMI will improve and the hospital will be in a better situation when it comes to insurance contract negotiations. Therefore, not only does HIM benefit from CDI, but also the hospital as a whole will see an improvement in the quality of care and future financial success.

CDI is a positive step to take in the improvement of clinical documentation at your hospital. It must involve all of the players—physician, coder, case manager, patient accounting and information systems—to be initially successful and to realize ongoing gains.

Donna Lee Steigerwalt is the manager of HP3’s CDI Products Division. She coordinates the monthly Coding Lunch ‘N’ Learn audio education series for coding professionals and is a frequent contributor to