AHIMA releases new CDI guidance, offers tools for programs

Two new publications from AHIMA offer guidance and best practices for CDI programs. The Clinical Documentation Improvement Toolkit, released in April, and the “Guidance for Clinical Documentation Improvement Programs” (aka the CDI Practice Brief), released in the May Journal of AHIMA, outline CDI job descriptions, provide examples of leading and non-leading queries, and suggest policies for verbal and written physician queries.

The guidelines needed to be specific enough to be useful but broad enough to allow facilities to make necessary adaptations, says Gloryanne Bryant, RHIA, RHIT, CCS, CCDS, regional managing director of HIM (NCAL revenue cycle) for Kaiser Foundation Health Plan, Inc. & Hospitals in Oakland, CA.