Improving the collaboration between CDI and case management

Clinical documentation improvement (CDI) specialists and case managers share a common goal but often aren't on the same page when it comes to improving documentation within the hospital, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, director of enterprise solutions for Zirmed, in Chicago. Organizations should shift the focus of CDI from merely capturing as many comorbidities and complications (CC) and major comorbidities and complications (MCC) to truly improve the written picture of the patient's condition.

This change in focus needs to do several things, according to Krauss, including the following:

• Recognize any barriers that exist between CDI and other departments they need to work with.
• Create a supportive environment and reporting structure for CDI that recognizes the limitations of strict reimbursement outcomes and realigns the focus of CDI toward processes and outcomes that incorporate the multitude of uses in today's fee-for-value healthcare delivery model.
• Define and agree upon what constitutes true CDI. This should reflect effective communication of patient care, outcomes, and fee-for-value to the mutual benefit of all healthcare stakeholders, including the patient.
• Revise the job description for CDI to give these staff members more encompassing duties and responsibilities and to better define clinical duties and responsibilities.
• Develop expanded and more refined key metrics of documentation improvement that are valid and meet inter-rater reliability.

By encouraging CDI to take a more comprehensive approach to documentation you'll not only improve their ability to work with case management, but also their ability to work toward more accurate billing and fewer denials.