HIMA350 Health Compliance
Assignment: Clinical Documentation Improvement Components
Clinical documentation improvement (CDI) is organized around standardized, accurate documentation to effectively manage revenue and treatment for medical necessity. As the coding supervisor, you are responsible for monitoring the queries generated by the coders – as a part of clinical documentation improvement initiatives. You want to make sure that the queries are written appropriately regarding content, appropriately worded questions, and documentation.
For this assignment, you will review physician queries and critique the content, develop steps to implement a CDI program, and recommend best practices to implement CDI reporting.
There are a number of resources that I am providing to you to guide you in regard to physician queries and CDI programs. Please review all of the attachments below. These seven (7) additional documents begin with the word “AHIMA”.
1. Evaluate the physician queries. They are attached below as PDF titled “HIMA 350 Assignment Clinical Documentation Improvement Components”. In a 1-page report:
a. Assess if the queries are well written.
b. Summarize your results.
2. Recommend improvements for the queries.
3. Based on your findings:
a. Identify trends.
b. Compare coders – which are better at writing physician queries?
4. Implement a CDI program plan to address the results of your query evaluation.
a. Overview. Describe the purpose of a CDI program and its benefits.
b. Team. Describe titles, roles, and team responsibility for each member’s role.
c. Software and Tool(s). Describe the type of software and programs that can be used to manage the program; consider computer-assisted coding software). Explain why you chose the tool(s) and how it will support program efforts.
d. Training. Construct a plan to train the CDI team and staff. Consider the topics and frequency of training and who should be involved. Outline recommendations for new staff and training maintenance activities.
e. Reporting. Outline how CDI will be reported, and trends identified for performance improvement.
f. Best Practices. Integrate two recommended best practices on the reporting process of CDI and benchmarking. Helpful benchmarks include ways to monitor case mix index, the number of days not final billed (DNFB) accounts, claims denials, and present on admission indicators.
Provide a rationale for each recommendation.
https://myclassroom.apus.edu/d2l/le/dropbox/22416/45022/DownloadAttachment?fid=469804. For more information on Health Compliance see this: https://www.encyclopedia.com/social-sciences-and-law/law/law/compliance
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