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I have heard it said that the overall goal of Clinical Documentation Integrity (CDI) is to improve documentation for coding and reimbursement. Even though this is in fact a valued outcome of many CDI programs, I argue that it is not the overarching goal of CDI today. With the ensuing complexity of technology, such as CAC, NLP, and AI it is even more imperative that CDI take a lead in ensuring accurate documentation not only for the sake of appropriate reimbursement but for the sake of patients’ clinical outcomes. I am not merely speaking to quality outcomes or risk adjustment – even though these are valid areas of focus – but instead digging deeper into items such as actionable data analytics and the associated research that drives our evidence-based healthcare system. Rodenberg and colleagues (2019), at Baptist Health in Jacksonville, Florida, took on four small studies examining the potential expanding role of CDI. They found positive results when addressing the need of CDI to expand clinically, however cautioned efforts to encroach upon the dotted line between accuracy of data and actual care.
There is one glaring piece of the puzzle that I have discovered over my years of practicing CDI, and this article, as well as the lack of further research, confirms it. Advocating for CDI as part of the care team is mostly taboo. As well, and for those of us having been part of the industry for a while, the balancing act of clinical coding and clinical medicine presents with a large chasm, and few learn to connect the dots and navigate it gracefully. Many will topple off the cliff and only a small number will hang on and try it again. For this reason, when choosing to press forward, we must develop the expertise of interprofessional collaboration and nurture mutual trust. This has never been more important than it is today and will become even more important tomorrow. Can CDI programs be used to supplement clinical insight? If so, then how does that look and what are the compliance issues that may arise? These obstacles must be addressed not only within the given organization but across the larger divide of health care policy…and it may take an acrobat with exceptional balancing skill to conquer!
Are you willing to step out on the tight rope? If so, then let’s chat!
Reference: Rodenberg, H., Shay, L., Sheffield, K., & Dange, Y. (2019). The expanding role of clinical documentation improvement programs in research and analytics. Perspectives in health information management, 16(Winter).
Written By: Jessica M. Vaughn, MSN, RN, CCDS, CCDS-O, CRC.
Vice President, Value Based CDI at Norwood.
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