One of the many management topics at the conference of the Association of Clinical Documentation Integrity Specialists (ACDIS) is having written CDI policies and procedures (P&Ps). Although at times writing policies and procedures can bring on a nauseous feeling, they also result in greater consistency and continuity within the workplace and the workforce. These written P&P can also improve Clinical Documentation Integrity (CDI) specific tasks and functions, that also assist to achieve CDI overall positive results.
Companies, businesses and departmental level policies and procedures allow for management and staff to have a greater understanding and value of their work and the specific functions that supports their job duties. P&Ps also help to establish the expectations of the role/job and even to ensure that the employees perform their jobs within the boundaries of ethics, compliance, and the law. In addition, having written P&Ps can help management with defending some employee complaints but also P&Ps help employees know who, what, when, where why and how to perform their job duties for the role they have.
Within CDI, having written policies and procedures are an essential part of any program and/or department. Whether inpatient or outpatient CDI, or both, management needs to put in place written P&Ps.
Some of the standard CDI P&P that are part of the CDI foundation include the following:
- CDI Query Process P&P
- CDI Query Compliance & Format
- CDI Query Retention P&P
- CDI Query Escalation P&P
- CDI Remote Work P&P
- CDI CEU Maintenance and Ongoing Education Requirement
Even having some P&P that define clinical criteria for specific diagnoses, can be extremely helpful to CDI. With greater payer denials based on their own specific clinical criteria, we all should be taking a closer look at having P&Ps that address the top 6-8 diagnoses that your hospital or practice has. A good first step is to run a diagnosis frequency report for the last 12 months and see what diagnoses have the highest frequency as a principal or primary diagnosis and those that are secondary (additional) diagnoses. Then bring together a multidisciplinary team with CDI, physicians and nursing management to determine the clinical criteria that you’ll be using or applying. This would be followed by education, not only in CDI and coding but also for the medical staff. Let’s remember that accurate clinical codes are often impacted by a documentation query that is sent to the provider for clarification and/or specificity.
Some of the elements to include in the P&P may be similar to the following:
- Company/Hospital Logo & Heading
- P&P Title
- P&P Number
- Effected or Impacted Department(s)
- Key Definitions (this can include abbreviations and acronyms)
- Policy (reason and/or rationale)
- Procedure (outline the steps and/or functions and/or tasks)
- Consequences (Failure to comply)
- Date approved
- Approved by (name and title)
- Next Review Date/Year
When developing a P&P it is a best practice to review it with your CDI staff and obtain feedback and input. Revisions might be needed to make the wording clearer or add or subtract some wording. In addition, you should establish a review cycle for your P&P. Most organizations and departments review their written P&Ps annually or bi-annually. If there is a significant regulatory change, such as an ICD-10-CM Guideline, etc., you may need to review and revise your P&P more often.
The ACDIS association’s annual conference is being held in Chicago this week and the theme this year is “Flourish.” The multiple day agenda includes the following topic categories:
- Clinical & Coding: A much-loved conference staple including core clinical and coding components vital to all those engaged in ongoing medical record reviews, perfect for those new to CDI as well as for those who wish to expand or refresh their knowledge.
- CDI Master Class: For those who wish to expand their professional skills and explore advanced concepts in CDI.
- Quality & Regulatory: An opportunity to explore the ways regulatory initiatives affect CDI practices, and the ways programs are meeting new challenges, by examining how documentation affects quality of care outcomes.
- Management & Program Development: A track devoted to expanding program parameters and innovating CDI staff/management experiences and expertise.
- Innovation & Expansion: An exploration of cutting-edge advancements including non-traditional settings, concurrent coding, data analytics, and outpatient CDI.
During the CDI conference there will be opportunities to learn more about ways to improve your CDI program and/or department and this includes having written policies and procedure. A great resource that can provide some additional information regarding CDI and querying is the ACDIS/AHIMA Practice Brief 2022, Achieving a Compliant Query Practice [see the link in this article References].
There is no time like the present to dust off your P&P, review them and update them, it is springtime now, so it is a great time to work on your P&Ps!
Programming note: Listen to Gloryanne Bryant today on Talk Ten Tuesdays, 10 Eastern, when she reports on new codes.