Understanding Clinical Documentation Integrity/Improvement

Posted on May 5, 2016 in Clinical Documentation | 0 comments

The transition to ICD-10 necessitates that physicians document more precisely, completely and consistently than before.

Clinical Documentation Integrity/Improvement (CDI) is the link between physicians and the coding department. Coders translate physician documentation into ICD-10 codes.

These codes are the basis of MS-DRG assignment, severity of illness, other risk rankings and observed:expected mortality scores.

Because coding terms are often not the same as commonly used clinical language, it’s not always obvious how to best document a condition. When clarity is needed, a query is a way to obtain this information.

There are two types of queries—CDI and coding. The former usually occurs during the hospitalization, the latter occurs after discharge. Queries aren’t trying to question your diagnosis, they are to help optimize your documentation.

Try to answer the CDI query promptly. Any clarified diagnoses should then be documented in the progress note and discharge summary.

If you don’t understand the query, contact the CDI team, especially before selecting the “unable to determine” option.

At Summit, call Ext. 7945 or 7946 to reach Sandra Christensen-Waldear, R.N., or Jane Banks, R.N., and 510-612-7085 to reach Beth Gong, M.D.

Please document diagnoses rather than just symptoms and lab findings (e.g. “pneumonia” rather than

“infiltrate and cough” and “lactic acidosis” rather than “elevated lactate”)

ICD-10 is about specifics such as acuity, type and etiology. For example, “acute diastolic heart failure due to rapid atrial fibrillation” is more specific than “CHF and atrial fibrillation”)

Clearly state conditions present on admission (POA) —especially catheter-related infections and pressure ulcers. Physicians should document the location of the ulcers but can leave the staging to the wound R.N.

It is important to be clear when there is an association or linkage between conditions. For example, it is clearer to the coder if you document “gastroparesis due to type 2 diabetes” rather than “gastroparesis in the setting of diabetes” or “diabetes and gastroparesis.”

When there is diagnostic uncertainty, inpatient coding allows for use of modifiers such as “suspected,” “possible” and “probable.” If a diagnosis remains “likely” or “suspected” at the time of discharge, be sure to document this in the discharge summary. Similarly, be sure to document when such diagnoses are “ruled out.”

Just because we can copy and paste, doesn’t mean we should. Without careful editing, inaccurate and outdated information keeps moving forward with copy and paste.

Specific words matter—physician documentation should be complete and precise for both the principal diagnosis as well as all the secondary diagnoses and co-morbidities—this is how you show how sick your patient really is.

By Beth Gong, M.D.
CDI Physician Champion, Alta Bates Summit

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