hello my him director believes that the coding templates and CDI templates need to be the same for compliance. How does your organization address this issue?
The fundamental process should be the same in regards to query formulation with the query written in observance of Industry Best Practice Standards. Query should have clinical support, cite context, offer responses that have compliant choices. Ideally, the workflow and clinical criteria employed by any person issuing a query should meet these expectations?
For example, if all recognize KDIGO as ‘the’ authoritative source for acute renal disease, and cite and use the same clinical criteria for any query issued for ARI, the query practice would be more consistent - IMO, I think the same criteria and standards should be used so as not to confuse the Medical Staff, too; it may be confusing to have differing workflows.
I agree Paul, consistency is important. We are performing the same function with query- it should be performed with consistent policies and and formatting. The AHIMA/ACDIS Query Practice Brief states, "All professionals are encouraged to adhere to these compliant querying guidelines regardless of credential, role, title, or use of any technological tools involved in the query process." that said there should be no need to have different formats or practices.
Totally agree with Paul and Laurie. The final product of CDI work is not only documentation integrity, but also the true complexity of the case reflected through coded data. In case of an audit, your organization might suffer if there is a discrepancy of clinical criteria for capturing the same condition. I am in favor of all queries to be performed by CDI team, but if in your facility coders follow up on retrospective queries, both teams should adhere to the same standards.
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Note from the Advisory Board: Take Time to Return to Basic CDI Training
For example, if all recognize KDIGO as ‘the’ authoritative source for acute renal disease, and cite and use the same clinical criteria for any query issued for ARI, the query practice would be more consistent - IMO, I think the same criteria and standards should be used so as not to confuse the Medical Staff, too; it may be confusing to have differing workflows.