Clinical Documentation Improvement Program

Report
Clinical Documentation Improvement Program
Physician Program Overview
Our CDI program works to ensure the documentation in the medical
record captures the true acuity of our patients. Accurate
documentation will reflect appropriate severity of illness and risk of
mortality to support resource intensity and length of stay for our
patients.
If a CDI nurse recognizes the need for additional documentation, a
question (query) will be presented to you. This packet is intended
to give you a little more information behind the program.
Clinical Documentation Improvement Program
Physician role:
CDI Nurse role:
•
Medicare Guidelines dictate specific words that must be
present in order to choose and apply a code for billing. It
is all about specificity.

Please clarify documentation as requested, when
appropriate, and include this diagnosis in your progress
notes and discharge summary.
•
Coders are not clinical and therefore not permitted to
assume, infer or interpret data to arrive at a diagnosis.

Prompt response to the query to get the documentation
into the record and avoid the necessity of a post discharge
query.
•
CDI Nurses perform a concurrent review of the medical
record. Analyzing and comparing current physician
documentation to clinical indicators and treatment. This
information is applied to coding guidelines to determine if
current documentation supports coding of accurate
patient severity at this point in time.

A query/question posed to the physician does not suggest
or require a positive response. As always please exercise
your independent professional judgment in responding to
the query.

Physicians cannot be expected to know all the coding and
documentation guidelines as they change too frequently.

Know that the Clinical Documentation Specialist is working
diligently to capture accurate patient severity for physician
profiling and at the same time provide resource
consumption accountability for the sustainability of our
hospital.
•
•
If inconsistent, missing or conflicting documentation is
identified, a physician query or clarification question is
posed to the physician.
A prompt response is necessary to get this documentation
into the record prior to discharge.
Take Away: Greatest level of specificity supports
additional length of stay and increased resources
required to care for the higher acuity patient
Clinical Documentation Improvement Program
Query Process
The physician is alerted of a query in SAC within the signature
manager as an incomplete document when you log into SAC.
Open the document, which will describe the clarification of
documentation that is requested. Review, modify and save your
response.
If unable to answer at that time, close and return when able to
determine.
Questions or unclear of what to do contact the CDI nurse listed on
the query.
Sample cases to show how documentation clarification impacts
your severity of illness (SOI), risk of mortality (ROM) and expected
LOS (GMLOS)to follow.
Clinical Documentation Improvement Program
Specificity : Specificity of anemia and diagnosis to support resource use
Before
DRG
Severity
Weight
Principal
Diagnosis
Procedure
Items to Clarify
165
1.8220
Lung CA
EBL 650 with drop in
H/H tx with 2 UPRBC,
Failed weaning requiring
2 additional days in ICU
on Vent
Wedge Resection
Secondary
Diagnosis
Anemia, failed
Extubation continue
vent
GMLOS
3.2
SOI ROM
1/1
Documentation to
Impact SOI
Acuity and etiology
of anemia. Dx to
support continued
vent support .
After
DRG
163
Severity
Weight
5.0332
Principal
Diagnosis
Lung CA
Added
Specificity/Severity
Procedure
Wedge Resection
Secondary
Diagnosis
Acute blood loss
anemia, Acute
respiratory Failure
GMLOS
10.7
SOI ROM
3/3
Impact: Increased Severity weight providing for 8 more days for needed treatment and
resources
Clinical Documentation Improvement Program
Specificity for : Sepsis due to UTI and Toxic Metabolic Encephalopathy
Before
DRG
661
Items to Clarify
Urosepsis maps to to
simple UTI when
coded
After
DRG
853
Severity
Weight
5.2068
Severity
Weight
1.8829
Principal
Diagnosis
Urosepsis
Principal
Diagnosis
Sepsis 2/2 UTI
Secondary
Diagnosis
Confusion
Secondary
Diagnosis
Toxic Metabolic
Encephalopathy
GMLOS
2.2
GMLOS
10.8
Procedure
Percutaneous
nephrostomy tube
Procedure
Percutaneous
nephrostomy tube
SOI / ROM
1/1
SOI / ROM
2/2
Documentation to
Impact LOS
Urosepsis = Sepsis 2/2
UTI
Confusion in the setting
of infection =
encephalopathy
Impact: Increased severity weight providing for 8 more days for needed treatment and resources
Clinical Documentation Improvement Program
Specificity : Type of Pneumonia and Severity of Malnutrition
Before
DRG
194
Severity
Weight
.9688
Principal
Diagnosis
HCAP – maps to
simple
pneumonia at
time of coding
After
Items to Clarify
Immunocompromised
patient treated with IV
Cefepime, Vanc,
Tobramycin, Zosyn.
Secondary
Diagnosis
Lung CA,
malnutrition
Documentation to
Impact SOI
GMLOS
3.8
SOI ROM
2/2
Suspected organisms
to support antibiotic
selection
DRG
177
Severity
Weight
1.9492
Principal
Diagnosis
Suspect Gram
Negative
Pneumonia
Added
Specificity/Severity
Secondary
Diagnosis
Lung CA, severe
malnutrition
GMLOS
6.2
SOI ROM
3/2
Impact: Increased Severity weight providing for 3 more days for needed treatment and resources
Clinical Documentation Improvement Program
Thank you for taking time to review our program information.
If you have questions or need additional information please contact
one of our team:
CDI Specialists:
Vicki Byrd, LPN
Debra Roth, RN
Laura Steffey, RN
Jan Hardy, RN
283-2137
283-2632
283-2137
283-2632
CDI Manager
Lisa Strother, RN
283-2358
Medical Director
William Templeton, MD 283-2777

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