Here’s a distilled and refined list of the top ten required components of an effective, high-performing Clinical Documentation Improvement (CDI) program that I have developed and fine-tuned over time. Every one of these components must closely align and work in tandem, utilizing a multidisciplinary approach that includes physicians, physician advisors, case management, utilization review, coders, and denials and appeals as part of an effective strategy to achieve sustainable net patient revenue. Of note is that these ten components are predicated on CDI recognizing that only physicians can improve their documentation with the assistance and guidance of the CDIS, working in collaboration with physicians to achieve physician documentation excellence through CDI-directed physician documentation training and knowledge sharing. Contrary to what CDI consulting companies peddling their AI/NLP software claim, technology is not the panacea for driving physician documentation excellence.
MISSION & PURPOSE Clearly Defined Mission: Ensure the CDI program has a clear mission centered on using medical records as an effective communication tool. Emphasize that physicians are integral to improving their own documentation.
- PROCESSES vs. TASKS Focus on Processes: Develop robust processes that go beyond simple queries. Provide ongoing education to physicians about documentation standards and serve as a resource and mentor to support effective documentation practices.
- TECHNOLOGY Strategic Use of Technology: Utilize technology as a supportive tool for managing and tracking the CDI program’s progress. Ensure that technology enhances rather than dominates the CDI processes.
- PEOPLE Skilled Professionals: Assemble a team with a passion for educating physicians on documentation rather than focusing excessively on querying. The team should be committed to training and knowledge sharing.
- KNOWLEDGE BASE Expertise and Competency: Ensure the CDI team has the necessary skills, core competencies, and a deep understanding of documentation principles to effectively engage with physicians both individually and in groups.
- EXECUTIVE SUPPORT Leadership and Collaboration: Secure executive support to break down silos and promote a multidisciplinary approach to CDI. Collaborate with Clinical Management/Utilization Review (CM/UR), Physician Advisors, Denials, and Appeals. Ideally, have a Physician Champion to advocate for and guide the CDI efforts.
- PROACTIVE MINDSET Preventive Approach: Foster a proactive approach to documentation that anticipates potential issues and educates physicians to prevent denials before they occur. Emphasize critical thinking and preemptive strategies.
- MEASURES WORTH MEASURING Effective Metrics: Move beyond traditional CDI metrics that focus on task completion. Implement measures that reflect the effectiveness of documentation improvements and their impact on patient care and compliance.
- QUALITY vs. QUANTITY Emphasize Quality: Focus on the quality of documentation reviews rather than the sheer number of reviews conducted. High-quality reviews lead to more meaningful improvements in documentation.
- FLOOR PRESENCE Onsite Engagement: Ensure that CDI professionals are present onsite to facilitate real-time interactions and support with physicians. Remote work may be less effective in fostering the necessary relationships and immediate feedback.
BONUS COMPONENT:
- Critical Evaluation of External Advice: While CDI consultants can provide valuable insights, it’s important to critically evaluate their recommendations and adapt them to fit your CDI program's unique needs and context.
These refined points will help structure an effective and high-performing CDI program. Feel free to reach out to learn more about Core-CDI’s unique approach to CDI that embraces the necessary components to achieve an effective sustainable physician-driven, physician-tailored CDI program geared towards proactive preemptive denial avoidance documentation.
Glenn Krauss is the is a well-recognized & respected subject matter expert in the revenue cycle with an emphasis & focus upon collaborating & working closely with physicians in promoting, advocating for, educating & achieving sustainable improvement in clinical documentation that accurately reflects & reports the communication of fully informed coordinated patient care. He recognizes the importance of complete documentation in denials avoidance.