CDI is Expanding as Need for Quality Documentation Grows

This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.


Clinical documentation improvement (CDI) programs are quickly emerging in various areas of the healthcare arena. We now see these programs specializing both prior to and beyond the acute hospital admission. Just as healthcare doesn’t stop when a patient is discharged, health problems begin before admission takes place. Prior to admission, an assessment must be made to determine if an admission is needed. After discharge, there is ongoing follow up and treatment to help patients return to normal daily life activities.

The documentation doesn’t start or stop at the acute admission either. The impact of CDI can be felt in many healthcare settings. Some of the areas that are beginning to implement CDI programs include the emergency department, long term care, home health, inpatient psychiatry, and inpatient rehab. The seven characteristics of high quality documentation that CDI emphasizes are important no matter what the care setting may be. These characteristics dictate that documentation should be:

  1. Legible
  2. Reliable
  3. Precise
  4. Complete
  5. Consistent
  6. Clear
  7. Timely

Even though the foundation of high quality documentation is the same, the review process and opportunities will vary by location. It is important for the CDI professional to understand the detailed documentation requirements in any setting in which they review medical records. Let’s take a look at some of the differences between care settings.

  • Emergency Department (ED): In the emergency department, it is imperative that the documentation fully supports the evaluation and management level and the outcome of the visit. Emergency room providers must fully support the reason for discharging or admitting the patient. The ED note is an important part of the patient story.
  • Home Health: Home health agencies are a valuable resource for patients who are ready for discharge but are in need of nursing care that can be delivered in the home setting. Home health nurses are required to fill out the Outcome and Assessment Information Set (OASIS), which focuses on the patient’s conditions and expected therapy needs.
  • Inpatient Psychiatry: It is crucial for all acute medical conditions to be stable before admission into a psychiatry unit. The focus of care should be on the psychiatric issues that are preventing the patient from functioning outside of the hospital setting. Psychiatry providers use the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) to bring in the needed specificity of all mental conditions. The DSM-5 helps providers document psychiatric conditions in great detail. With the focus on psychiatric conditions, however, chronic comorbidities may not be documented to the highest level of specificity.
  • Inpatient Rehab: Inpatient rehab facilities (IRF) are in place to prepare the patient for a return to normal function. They use the Patient Assessment Instrument (PAI) for their documentation. This assessment tool will place patients into groups based on the clinical picture and expected resource that will be utilized. Rehab facilities must closely document the therapy needs of the patient to support continued rehabilitation within a facility.
  • Long Term Care: In long term care, nurses have to fill out the Minimum Data Set (MDS), which has fifteen categories of information that must be documented. Residents in long term care are well enough to move beyond acute care but still require some nursing assistance. In this setting it is imperative that the resident’s functional status is clearly defined and identification of all medical conditions are made to give a clear picture of the patient’s health status.

As you can see, provider documentation is crucial to support patient care in all settings. Each of the settings mentioned above has their own prospective payment system (PPS). Just like acute care, high quality documentation is the only way to support appropriate PPS assignment and truly reflect all of the diagnoses being treated and echo the quality of care that was provided.

What areas are you seeing CDI expand in your own organization? Any settings different than the ones mentioned above?

Tammy Combs, RN, MSN, CDIP, CCS, CCDS, is director and lead nurse planner of HIM Practice Excellence for AHIMA. She provides professional practice expertise to AHIMA members, the media, and outside organizations on clinical documentation improvement (CDI) practice issues. Combs authors material and provides support for AHIMA’s online CDI education platforms. She also serves as faculty for the AHIMA CDI Academies and CDIP Exam Preps, and is a technical advisor for AHIMA on CDI publications.

8 Comments

  1. I see that CDI efforts are expanding to the psychiatric setting but I have been having difficulty finding information pertaining specifically to the inpatient mental health/psychiatric specialty. If you know of any resources, please share. Thanks!

    Post a Reply
    • Hi Tunisha,

      The seven characteristics of high quality documentation are the same in all areas of specialty. With inpatient psychiatry, it is imperative that all psychiatric orders are documented in accordance with the recommendations of DSM-5. Many times with the psychiatric patient, it is the specificity of the medical co-morbid conditions that get overlooked.

      I have some resources listed below that I would recommend:

      • Clinical Documentation Improvement: Principles and Practice
      • Recognizing the Characteristics of Quality Documentation
      • Mentally Prepare for Psychiatric Classification Changes: Industry Moving to DSM-5 Revision
      • CDI Toolkit
      • ICD-10-CM/PCS Documentation Tips

      I hope this helps!

      Tammy

      Post a Reply
  2. I have been a ProFee Coding for the last 8 years and am very interested in doing CDI for the ED. I have been approached by Head Hunters and once they hear I have no inpatient experience, the conversation quickly is discontinued.
    However, I do have ProFee Coding experience in Critical Care, Urgent Care, Hospitalists, Cardiology and Primary Care, as well as Physician Coding Education experience as well. Every position posted that I have reviewed is required to have Inpatient Coding Experience with an RN.
    I have worked in Epic for 10 years as well as Excellian for Allina Health in MN. Do you have any suggestions as to how I can get past the Inpatient, RN requirements?

    I would be happy to forward my resume to you for you to review, any suggestions would be greatly appreciated.

    Jacquie Biegner-Carlson, RHIT
    Stacy, MN 55079

    Post a Reply
    • Hi Jacquie,
      It is challenging when an employer requires experience that you have not acquired. You may look to see if any of the positions you are interested in would substitute the experience with education. If so then you may consider is attending some CDI education that includes inpatient focused content.
      You might consider the CDI Academy or the CDI online courses. Here is the link to the CDI website at AHIMA http://www.ahima.org/topics/cdi. You can find a list of our CDI resources to see if another product may be a good fit for your needs.
      I hope this helps,
      Tammy

      Post a Reply
  3. AAPC has a new credential just for this area. I would like to know if positions will be opening up for those who don’t have inpatient experience and are not an RN. I’m assuming there must be openings forthcoming for the outpatient setting other than at home and the ER. Members in our chapter are interested in getting the new credential but don’t want to waste time and money if positions aren’t going to be opening up to the outpatient/pro fee settings.

    Post a Reply
    • Hi Joanna,
      There seems to be a good deal of interest in outpatient CDI. We have no guarantee of when outpatient CDI positions will be opening up or what experience and backgrounds employers will require. However, this does open a door of opportunity for outpatient and pro fee coding professionals to reflect their skill sets to potential employers. The avenue taken to present those skills that will depend on the individual and the goals of their career plan. Professional organizations are beginning to offer more education focused on CDI in both inpatient and outpatient settings, which could present opportunities as well.
      I hope this helps,
      Tammy

      Post a Reply
  4. CDI program is highly needed for every Facility.I used to work as a Surgical Ward Nurse for 2 years then an outsourced coder for 4 &1/2 yrs both IP and OP,I must say that experience whether IP and OP is very vital to be an effective Clinical Documentation Specialist, every chart is like a puzzle that needs to be put together..

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  5. Heads up on the outpatient CDI initiative – In the state of MN, already have CDI Educators with coding and/or RN back ground traveling to clinics to educate new providers and continue lunch and learns and ongoing education regarding queries etc.. Yes, in the outpatient and ancillary sector.

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