By Julius Blum
Vice President, Portfolio Architecture & Integration, Streamline Health, Inc.

As providers begin to see the effects of ICD-10, it becomes more important than ever to review your Clinical Documentation Improvement (CDI) program. The increased specificity that ICD-10 demands, along with the productivity concerns, provides the impetus to not only improve your documentation, but also all your processes around CDI. Succeeding now means we need to work smarter, and that reinforces the need for a multi-faceted approach to maximize our CDI results. Whether you have a well-established CDI program, are just getting started or somewhere in between, here are five areas to review to ensure you’re getting the most out of your CDI efforts.

1. Know your numbers. If you don’t know the problem areas, you won’t be able to make the necessary adjustments to improve and move the needle in areas that influence your results. Metrics are essential and they shouldn’t take long to compile. Some of these metrics are:

  • Top query reasons
  • CDI productivity
  • Most queried physicians

2. Hone the query process. Physician queries will increase significantly due to ICD-10 and reviewing the entire query process will pay off significantly. If your query process is manual, consider electronic physician queries that can easily be tracked. This enables you to identify turnaround time and calculate the potential value of each query. Getting this degree of detail will enable you to identify areas for improvement and work with all stakeholders to optimize results.

3. Communication & Collaboration. CDI specialists and coders should work closely together and have the ability to share their case reviews, coding and DRG findings, and queries.  Hold periodic meetings to keep team members informed about the technology, changes in processes and overall progress. This maintains forward momentum and is crucial to the success of the program.

4. The right technology. Choose software that includes workflow processing, automatic follow-up assignments of CDI workload, tracking working DRGs, the ability to suggest queries, and of course, robust reporting.

5. Explore other opportunities for CDI. Expanding CDI to non-inpatients is a growing trend that can be a beneficial area to pursue due to expansion of recovery auditors for the outpatient population. Outpatient surgery and observation patients that get admitted require the supporting documentation as to the reasons for admission. Your CDI program can help physicians document these properly.

In this era of tightening margins and increased scrutiny, having a solid CDI program is no longer a “nice to have” luxury. It’s a necessary element that reinforces the processes and results your Management and Board are focused on as they look for ways to succeed in today’s healthcare market. Following the steps above will help your organization ensure your CDI efforts are supporting those efforts.