News: ACDIS Quarterly Conference Call focuses on quality opportunities

CDI professionals have been taught to search the medical record to clarify conflicting or inconsistent documentation and catch apparent diagnosis omissions, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDIS, CCDS, an ACDIS Advisory Board member and independent consultant based in Madison, WI. Catching a single mistake or asking a physician to document a more specific diagnosis once in the record doesn’t necessarily lead to overall improvement, however, as Recovery Audit Contractor (RAC) more frequently deny claims that lack consistency.

 

“We are creating a financial liability for our facilities if the RAC only takes back documentation improvement dollars six months down the road," he says. "It’s like a shoe salesman who works on commission; they don’t get to keep that commission if the customer brings those shoes back to the store. It’s the same thing for CDI programs. We need to make sure the entire medical record is clear from beginning to end.”

 

Krauss suggested that CDI managers open a dialogue with CM and other team members to identify additional opportunities for documentation improvement and better collaboration across traditionally siloed departments.

 

The conversation was timely, according to ACDIS member Donna Kent, of Torrance (CA) Memorial Medical Center. “Yesterday my vice president of quality had a conversation with the CDI team regarding a recent case management conference she’d attended. Apparently a lot of what was discussed was this point of people working in silos, where CM and CDI professionals are thoroughly in the chart but not working together collaboratively to illustrate the complexity of the medical record. I think it’s a good idea to work collaboratively but I think [we need to be careful]. It would not be beneficial to have either [the CM or CDI] role suddenly have to take up the role of the other professional. We should work together.”

 

Read more about this combined function in the Q&A below.

 

Editor’s Note: ACDIS members can download Krauss’ powerpoint presentation and listen to a recording of the call under the Quarterly Conference Call tab on the ACDIS website.