Upon review of medical record cases, discussion of opportunities for documentation improvement of diagnoses and procedures regarding their level of specificity and presence on admission. Review of queries regarding potential fraud and/or compliance issues, conflicting diagnoses, abnormal findings, and post-discharge query opportunities. Review of requirements for documentation of query response, tracking of queries. Develop policies for documentation of query responses in the record to establish official policy and procedures related to CDI query activities. Develop policies regarding various stages of the query process and time frames to avoid compliance risk.
Identify the principal and secondary diagnoses in order to accurately reflect the patient’s hospital course. Using coding software , assign and sequence diagnostic and procedural codes following all coding conventions and with consideration of payer requirements for appropriate code assignment and assign appropriate DRG codes, when appropriate. Use reference resources for code assignment.
Develop educational sessions with staff to discuss common metrics and methods for their development, such as denials, physician query response, query volume, working DRGs vs final, and the development of program success metrics. Given sample data, develop methodology to trend and track query content and provider and develop CDI benchmarking. Develop and provide educational sessions on the implications of accurate coding and the need to assign diagnoses and procedures to their highest level of specificity and the implications of accurate coding with respect to research, public health reporting, case management, and reimbursement.
Development of physician education regarding their rights and responsibilities in a CDI program. Maintain and analyze query documentation. Apply AHIMA best practices and all regulations to CDI policies and procedures, in coordination with compliance department. Advocate for CDI within an organization and foster relationships with CDI team members and physician champions for reconciliation of queries. Create and support a process for resolving unanswered queries.