Two key efforts in this vein include leveraging an EHR system and developing a sound policy or procedure.
When it comes to clinical documentation integrity (CDI) programs, healthcare organizations frequently struggle in ensuring that clinical documentation for each encounter is clear, concise, and reflective of patient’s hospital stay, while also holding some encounters in an unbilled state to collect such quality documentation via CDI query process.
The American Health Information Management Association (AHIMA) specifies that a query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment for an individual encounter in any healthcare setting. Synonymous terms for “query” include clarification, clinical clarification, and documentation clarification.
Many organizations with successful CDI programs have two things in common. One, they leverage their electronic health record (EHR) system to assist and speed up the query process and communication. Two, they adopt a strong written policy/procedure on how the entire query process is to work, with some “if, then” statements.
With regard to technology, simplifying the query process for clinicians is the key to success. One common tip is to utilize EHR communication tools to assist clinicians in today’s hectic world. Many EHRs offer message center/inbox communications tools. One thing that has consistently worked for successful CDI programs is to place CDI and coding queries in one electronic location/folder of the EHR, and on the top of the inbox/message center. This will ensure communication to clinicians that CDI and coding queries are a collaborative effort, and clinicians will not get the queries and communication in different areas of the EHR, hence establishing high priorities for both. Also, making queries simple by utilizing pre-built templates familiar to the physicians can assist in simplifying the process.
To ensure the appropriate time between origination of a query to the final answer by the clinician, as noted, a strong policy and/or procedure should be created, in collaboration with health information management (HIM), revenue cycle, and medical staff, and it should be communicated to all parties involved. For example, consider outlining the entire lifespan of a query with clear timelines and responsible parties’ proofs to be highly efficient.
Healthcare organizations need to make a decision on how long they are willing to keep a query in an unanswered state before dropping the claim for billing. On one hand, keeping a query out for longer periods of time to provide clinicians ample time to complete the documentation might help to capture the best documentation for the encounter. On the other hand, if the encounter remains pending for a long period of time, it can inflate discharged not final billed (DNFB) totals. The clinician then might forget some details as time passes from the time of treatment, and this can also hinder reimbursement due to various contracting limitations.
Creating a strong CDI query policy can get organizations to the best of both worlds. Inserting “if, then” statements can help as well. For example, statements like “if” the physician doesn’t answer the query within two days, “then” the query request is getting escalated to executive leadership for a one-on-one conversation with the assigned clinician. Or “if” the query is outstanding more than seven days, “then” it is finalized; however, documentation of the lost opportunity will be presented to the medical staff committee for the review and corrective actions.
Having worked in clinical documentation integrity (CDI) in a variety of roles, I have heard a lot of advice when it comes to the timing
Let’s talk about the term “attending physician.” The simplest definition is the physician primarily responsible for a hospitalized patient’s care. While there may be many
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