Feature: Define outpatient CDI nuances in the emergency department

by Anny Pang Yuen, RHIA, CCS, CCDS, CDIP

The role of a CDI specialist is to ensure physicians' documentation accurately reflects their clinical judgment and medical decision-making, as well as the acuity of patients; therefore, having a CDI presence in the ED will lead to fewer medical necessity denials.

Outpatient CDI is like Pandora's box, especially in the ED. So, outpatient CDI tasks may be different from one organization to another. Some programs may have their CDI specialists review provider and nursing documentation for evidence of patient monitoring, along with compliance of physician orders and confirmation of diagnoses. Others may have the CDI team evaluate and monitor documentation of observation hours from a compliance standpoint, and/or review and educate physicians regarding the importance of accurate documentation of infusions and injections.

Since CDI specialists are documentation educators, it makes sense for the CDI team to expand its education to the nursing team on the requirements for documentation of infusions/injections. By comparing provider and nursing documentation to charges, organizations can ensure that charges for supplies and medications are appropriate for the services documented.

Editor’s note: The article was originally published in the CDI Journal. Members can read the full article here. Yuen is an ACDIS Advisory Board member. Contact her at anny.p.yuen@gmail.com.