Creating a CDI program
I am reaching out the ACDIS community for help. My organization has been trying to create a CDI initiative but are continuing to have little recognition of our efforts. I am employed under HIM and have worked hard to educate myself about the CDI in and outs as well as working very closely to our inpatient coder. We are a small organization and do not have any software in place to aid in our processes nor the backing of our CMO. There is a strong history between the CMO and my current Director which is not helpful but toxic. I guess the other piece of information that I need to interject is that the CMO believes that the only individual who is qualified to do this position is an RN, my background is in Radiology but 20+ years in Cardiac Cath Lab.
I appreciate any and all help or suggestions.
Thank you,
DSCHR
Comments
1. Endeavor to complete the ACDIS boot camp, either live or virtual. It will provide you with much background and context
2. Avail myself to all of the free guidance offered in the Resources Section on the ACDIS site.
Best: Paul
You mention there is a "strong" history between your director and the CMO. I would challenge you to approach the CMO and have a discussion regarding what your goals are (ie. a more accurate and complete record). I would also ask you...who decided to implement the CDI program? I would have them there to assist in the conversation (unless it is your director), then you might want to tackle it yourself. Once you start developing the relationship w/ your CMO. You need to get out and talk with the Providers. The better the relationship you have with your Providers, they more likely they will respond to your queries and education!! I am rather new to CDI, Started in March 2017. We had a rocky start, but we currently have 3 CDS's for a 150+ bed pediatric hospital (Dayton Children's). We are usually in the 85-90% response rate to queries.
Good luck and remember...You will have good days and bad days. Keep positive and keep pushing!
Take care,
Jorde
Hello! I come from a small facility (42 beds). I started as a medical coder and then created our current CDI program in 2013. I am still running the program and we do not have a nurse on staff. There are a lot of discrepancies in regard to CDI only being led by nurses. Is it easier to teach a nurse about coding or critique a coders/or yourself clinical skills they already know? I did go through a boot camp and I also have done a lot of research on my own. I believe I am just as clinical as a nurse plus I know all of the rules and regulations behind coding. When I initially created the program our CFO wanted to have a nurse run the program, I challenged it since I created it and would have to train the nurse.
Anyhow, we did not have software when we started either. I started small by taking samplings of patients to see if the program would make a difference. I tracked EVERYTHING on an excel spreadsheet. I used a standalone encoder to note my DRG baseline, DRG working, and final DRG in addition to MCC/CCs. I also obtained our medicare rate so I could manually compute the difference in reimbursement. If you want to know more please feel free to contact me. nloshaw@mhc.net
Nichole
Nichole: You bring up an issue re: using various professionals as CDS. AHIMA, one of four of the Cooperating Members, issued a "Clinical Validation" 2019 Update - The Next Level of CDI, in which it is made very clear that the role of CDI is not restricted to only one profession.
This document is copyrighted, but all should read it in detail as it discuss in details updated concepts regarding how CDS should function to ensure accuracy in documentation. An excerpt from pg, one follows:
"Depending on the needs of the organization, the clinical validation query (clarification) process is typically performed by CDI and coding professionals with a variety of backgrounds (registered nurse (RN), HIM coding, MD/DO, foreign medical graduate (FMG), etc.). As organizations may utilize a wide range of professionals with differing backgrounds and roles to send queries, this Practice Brief will refer to these professionals as query professionals throughout the rest of this document"....
"Those working in the role of query professional are not expected to establish diagnoses, but they can identify potential gaps in the clinical picture and send queries to clarify. Consequently, physician engagement is essential for a robust clinical validation process.
When a query professional writes a clinical validation query, they are not performing clinical validation. Rather, they are highlighting a potential gap between a documented diagnosis and the clinical evidence in the health record. The diagnostic decision remains the responsibility of the treating provider"....