Running a Successful CDIP

Clinical documentation improvement programs can enhance the clinical record and capture lost reimbursement. But they can be a challenge. Getting physician buy-in, avoiding turf wars between documentation specialists, coders, and nurses, and measuring program success are just a few of the challenges many facilities face with their programs. Below are a few tricks of the trade on running a successful CDIP, lent by experienced clinical documentation specialists.

Physician Cooperation

  • Find a physician champion, since physicians will usually listen to other physicians. Approach those physicians with excellent documentation practices and an interest in coding issues.
  • Start off the program slow, gradually integrating different departments and groups of physicians, says Linda Haynes, RHIT, documentation specialist with Legacy Health Systems, located in Portland, OR. Assure physicians you are not trying to change the way they practice medicine.
    Be persistent and patient. Some physicians will follow the CDIP for a while, then slack off answering queries, says Lori Schmitz, RHIA, the DRG coordinator with Mississippi Baptist Health System, based in Jackson, MI.
  • Physician education is key. Attend their staff meetings; put up flyers and posters in the physician’s lounge and dictation areas. Create pocket cards with documentation reminders by specialty, Schmitz suggests.
  • Illustrate how better documentation more accurately reflects risk of mortality and severity of illness, says Joan Enloe, RHIT, director of medical information, documentation integrity and utilization management at Greenville Memorial Hospital, in Greenville, SC. This shows that the CDIP is about more than reimbursement—it results in better care and a clearer physician report card.

Avoiding Turf Wars

  • Getting clinical documentation specialists and coders to get along can be tricky. This may happen most frequently when the CDSs are nurses. Try using a facility’s coding auditor or coding specialist as the go-between. This has worked great at Legacy Health Systems, Haynes says, as the coding auditor is seen as an expert in both coding and clinical information.
  • Hold a “meet and greet” session in neutral territory (perhaps off-site) so that coders and CDSs can get to know each other, recommends Joyce Leppo, CCS, inpatient coder with Gettysburg Hospital, in Gettysburg, PA.
  • Show respect. Acknowledge that each side has something to learn from the other, says Betty Bean, RHIA, consultant with HealthPort, based in Clarksville, AR.
  • Include both CDSs and coders in the program planning process. This builds teamwork from the start, says Colleen Lunski, RN, clinical documentation specialist at Altru Health System in Grand Folks, ND.

Measuring Success

  • Track as much information as you can about your program, using statistics to mark improvements and downtrends, says Joan Enloe, RHIT, director of medical information, documentation integrity and utilization management at Greenville Memorial Hospital, in Greenville, SC.
  • Track physician response rates and present those to the medical staff advisory board, Enloe says.
  • Don’t measure productivity solely on the number of queries submitted. Fewer queries could mean physician acceptance of the program. More queries could mean less acceptance.
  • Do a post-discharge review of the chart to ensure that all documentation obtained by query was considered for coding, Haynes says.

 

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