Guest Post: AHIMA director touts CDI efforts and importance of HIM involvement

by Lou Ann Wiedemann, MS, RHIA, FAHIMA, CPEHR

The HIM profession is constantly changing. The delivery of healthcare is in flux, as are documentation requirements and payment for healthcare services.

In the first edition of Manual for Medical Records Librarians, published in 1941, author Edna K. Huffman defined the medical record as “a systematic compilation of data pertaining to the patient’s illness or condition, sufficient in degree to justify the diagnosis, to warrant the treatment, to show the progress of the case, and to state the end result.”

Today’s electronic health record (EHR) certainly looks nothing like the paper chart that Huffman likely envisioned when she wrote her book. However, even despite these changes, HIM professionals’ responsibilities to maintain the integrity of the record remain largely the same.

Providers currently face massive and unprecedented technological changes. Incentive payments based on meaningful use of EHR systems, as well as the implementation of ICD-10-CM/PCS, are initiatives that affect the industry today.

HIM professionals possess the skills necessary to lead both of these initiatives. In particular, they have expertise in the legal health record, clinical terminology, regulatory requirements, and clinical coding. HIM professionals also provide input on how to better capture quality measures that increasingly affect reimbursement methodologies.

The intersection of CDI and HIM
HIM professionals play several key roles in the standardization of clinical documentation that affects patient care, research, coding, EHR implementation, and healthcare planning. They provide education to physicians, clinicians, and administrators about the importance of standardizing all clinical documentation so that these standards are incorporated into EHR templates.

HIM professionals can—and should—also play a role in CDI. CDI programs help alleviate documentation difficulties associated with the transition to ICD-10-CM/PCS, and can help capture meaningful use requirements. CDI professionals also help:

• Ensure overall compliance
• Capture medical necessity
• Prepare for multiple external audits
• Implement continual code updates

Perhaps most importantly, CDI specialists improve patient care by ensuring that there is clear and consistent documentation in the medical record on which multiple providers may base decisions for the patient’s treatment.

When HIM professionals become involved with CDI efforts, they engage with nurses directly and help to assign codes concurrently. CDI is based on concurrent chart reviews that take place before a patient leaves the facility.

CDI professionals, many of whom have coding/HIM backgrounds and expertise, work with members of the clinical staff, such as nurses, physicians, and therapists, among others. They interact with and educate these individuals about the importance of clear and concise documentation.

When coders have access to complete, accurate, legible, and timely documentation, the coding process is generally smooth and seamless. Documentation requirements will continue to increase in complexity, and organizations or providers may face a compliance risk if they fail to recognize the importance of how ICD-10-CM/PCS, reimbursement changes, and other healthcare initiatives affect documentation.

Although hospitals may implement a CDI program to ensure compliance with clinical documentation requirements related to reimbursement, a successful CDI program will affect much more than that. CDI ultimately affects patient care, and it assists clinical providers in documenting the severity of the patient’s condition. Clear documentation, in turn, allows for specificity in coding.

HIM professionals must help to educate physicians about the importance of CDI. Many times, physicians don’t understand the clinical coding and reimbursement documentation requirements. Instead, they rightfully focus on providing patient care. This is why it’s crucial for HIM professionals working in CDI to bridge that gap for physicians and to be their partner in quality documentation.

Physicians need to understand that HIM and CDI professionals can’t make any assumptions about documentation—physicians must be as specific and explicit as possible. Physician cooperation and acceptance is critical. Without physician buy-in, a CDI program may be destined for failure.

Knowledge and skill set
CDI is an exciting, fast-paced, and rewarding profession for those who pursue it. HIM professionals are certainly qualified to become CDI educators, critical thinkers, and innovative communicators. If HIM professionals are passionate about affecting the quality of patient care, they shouldn’t overlook this opportunity.

Every hospital’s CDI program is slightly different. Some hospitals employ coders and CDI nursing professionals who work side-by-side, which encourages close communication regarding documentation needs as well as coding applications and processes. Others separate the coding application process from the documentation improvement process.

Facilities can use either method because no cookie cutter approach exists. However, at a minimum, all CDI professionals should possess the following skills:

• Clinical background or understanding of clinical processes
• Strong understanding of coding application, rules, and guidelines
• Exceptional written and verbal communication skills
• Robust critical thinking skills
• Capability for detail orientation
• Outstanding organization skills
• Ability to work independently

HIM professionals possess all of these skills and already routinely review medical records, which makes them more than qualified to serve in CDI roles.

For example, coders review records and apply critical thinking skills to appropriately assign clinical codes. Coders also review records to craft compliant queries to physicians, when appropriate. These valuable skills allow HIM professionals to successfully transition into CDI positions.

CDI does require a strong clinical background as well as an understanding of disease processes. Coders hoping to move into the CDI realm must be able to discuss clinical indicators with physicians and other clinical providers.

For example, consider a patient who is admitted with nausea, vomiting, headache, and confusion. These are all signs and symptoms of hyponatremia. The patient’s blood work shows evidence of a low sodium count. Physicians may document this in one of several ways, such Na 119, decreased Na, or Na with a downward arrow.

The physician orders a normal saline IV and repeat sodium test. A coder can’t code hyponatremia because the physician hasn’t explicitly documented it. However, a coder who is trained as a CDI professional would know how to interact effectively and query the physician about hyponatremia based on the clinical indicators documented in the record.

Editor’s Note: Lou Ann Wiedemann, at the time of this article's original release, was the director of professional practice at AHIMA in Chicago. This article originally published on JustCoding.com.