Clinical documentation improvement: Issues for coders, CDI specialists, and physicians

Clinical documentation improvement: Issues for coders, CDI specialists, and physicians
3M live Q&A on February 21, 2013
 This is an excerpt from a 3M webinar held on February 21, 2013.

3M experts discussed clinical documentation issues faced by coders, CDI specialists, and physicians.

Barbara Aubry, senior regulatory analyst, 3M Health Information Systems, started the discussion with the following question about physician engagement in clinical documentation improvement.

Other 3M experts discussed the role of coders, CDI specialists, and others.

Q: Are your physicians actively engaged in documentation improvement?
A: Webinar polling results We’re seeing about 60 percent of physicians as actively engaged in documentation improvement.

Q: Are physicians buying into clinical documentation improvement as we arrive on the horizon of ICD? 
A: Panelist Barbara Aubry Those with an open mind who see the value of technological improvements are more willing to document and cooperate. I think those who find it very burdensome are pushing back because they feel their time is not well spent focusing more on documentation and less on patient care.

A: Panelist Donna Smith Senior 3M consultant I think it’s important to use the data to engage physicians in their own language, rather than focusing on the reimbursement aspect. Focus instead on severity of illness, risk of mortality, that kind of data. That speaks to them. They like to get very involved at that level.

Also it is helpful for HIM staff to get a physician champion or a medical staff champion to help them bring things into a physician’s language and help them communicate with the physician staff. A lot of times coders use “coding speak,” and we want to change that into a “clinical speak.”

[LIKE NURSES DOING IT! -- Joyce added for emphasis]

A: Panelist Barbara Aubry Yes. It helps to remind physicians that the data is not only used for billing purposes. You can help them understand that if their data is accurate, it will improve clinical outcomes.

Q: What is your opinion about coders assigning present-on-admission indicators by the timing of the test results?
A: Panelist Donna Smith Sometimes coders have problems assigning POA because they don't see the clinical picture.

The CDI staff often needs to query because they can see the abnormal test results. Sometimes the physician doesn't say the diagnosis until much later in the stay, and if you're going to be compliant, you might want to have them reference that it is POA

A: Panelist Garri Garrison Director, Emerging Business   If the clinical findings are very vague to support what the POA status is, that's where your CDI specialist should step in and start to ask those questions so that it's already defined by the time it gets to coding.

And sometimes you don't know the timing of lab tests. Maybe it was done six hours after admission, so you wouldn't have known if it was present on admission or if it occurred related to some treatment plan administered in the emergency department.

 Q: What is the danger when physicians “clone” (cut and paste) documentation in the EHR for patient visits?

A: Panelist Barbara Aubry When you look at a cloned record, you'll see the review of systems, the prior medical history, and diagnoses that are dragged along. I've seen charts where the patient has had the flu for more than 11 months.

You may have a coder who's assigning the E&M values based on cloned documentation when the physician didn't perform at that level on the specific date of service that they're coding for.