This monthly column will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.
By Autumn Reiter, BSN, RN, CCDS, CDIP, CCS, AHIMA Certified ICD-10 Trainer
When I explain my role as a clinical documentation specialist to people, the first question that comes up most frequently is the financial impact of my job. With the plethora of information given to the public via medicine-related dramas and news broadcasts, it is no wonder they ask this question. While the healthcare industry in the United States is complex—as health information management professionals are well aware—the end goal of clinical documentation improvement (CDI) is to promote the accurate “story” of each patient’s stay. When people get this answer, their response is often a perplexed look accompanied by the question, “But you are trying to get more money, right?”
It seems lately that every time you turn on the television there is a new medical drama starting. Unfortunately, the depiction of healthcare and the patient encounter is offered in a very skewed view depending on the storyline and intended impact. Some have gone as far as to note that any financial impact should be over looked and that it is a discredit to the profession to be cognizant of the financial burdens and rising healthcare costs. Although cost of care should not drive healthcare providers’ treatment decisions, accurate documentation is essential to obtain payment for the services rendered and assign the proper codes associated with those services.
But our jobs do not end there. We help ensure accurate data is collected for reporting, that the information the public is receiving via the public reports is correct, and that they are informed about facilities care and services. We review quality components and safety measures, all of which helps healthcare consumers make informed decisions on where to receive healthcare and who will provide that treatment.
The following analogy is a useful illustration to help those new to the CDI profession understand the impact of CDI. Let’s say you were seen at your local hospital, but six months later you take a trip to Europe and become ill. The providers there request your records from the states to help treat you accurately. Although there is potential a spoken language barrier, if the ICD-10 codes are as accurate as possible, there should be no concern. These function as a language of their own and it is the responsibility of CDI to make sure those codes fully depict the diagnoses noted. When we discuss any item, being as descriptive as possible creates a picture of what we are discussing. I can tell you I have a bike, but if I describe that bike as being a blue and white road bike, then the picture is much more clear. In turn, a provider’s note can say the patient had pneumonia, but if we can capture aspiration pneumonia due to swallowing difficulty following CVA, the picture again is very different and paints a clearer picture. CDI professionals are the translators for the language of ICD-10. They serve as the editors to each patient’s healthcare novel, each chapter closely reviewed for increased specificity that will allow for a more accurate story to be told through their reviews, queries, and conversations with providers.
Even though CDI professionals are not providing care at the bedside, they are still helping patients—just in a different way. It is essential for all CDI professionals to make sure each record is as accurate as possible, and that the providers understand the importance of the details in their documentation and the impact that has on their patients’ care—as well as the impact these details can have for the organization. Hospitals are businesses, and, yes, there is also a financial impact aspect to the importance of CDI as well—but that is only a small piece in a much larger story.
Autumn Reiter (autumn.reiter@TrustHCS.com) is director, CDI services at TrustHCS.