We can assist in the design and implementation of a HIPAA compliant CDIP that teaches documentation specialists (a seasoned coder or nurse) how to query physicians concurrently following AHIMA guidelines. This results in complete physician documentation and ensures that diagnoses appropriately reflect the patient's severity of illness, as well as intensity of service for patient encounters.

We train the documentation specialist how to perform the concurrent review process of the medical record. The documentation specialist learns key elements for chart review and correct MS-DRG assignment. This ensures that the billed diagnosis is indeed the principal diagnosis. This method also verifies that:

  • The principal diagnosis was present on admission.
  • That all secondary diagnoses were present or not present on admission.
  • The patient received treatment and/or evaluation for the condition during their hospital encounter.

Our method teaches documentation specialists to validate that their communications with physicians have an impact on the MS-DRG assignment, and to improve the documentation quality on every medical record.  It is highly recommended that a physician champion be the liaison between the clinical documentation specialists and the physicians to ensure the programs success.

Documentation specialists will use statistical data from the concurrent documentation process to show administrators how the facility can capture reimbursement that otherwise would have been lost. We assist the documentation specialist on how to create and perform coding quality monitors as a part of the hospital's compliance plan.  We have designed a mechanism for tracking and measuring data that provides reports with the MS-DRG weight differences from the physician query responses as well as which physicians are compliant or non-compliant with the program.

Key features of our CDIP training:

  • Review the medical record for complete and specific documentation.
  • Concurrently query physicians to document diagnoses for the patient's admitting signs and symptoms to support the medical treatment rendered following AHIMA guidelines.
  • Develop Standards of Conduct.
  • Strive to get the most resource intensive MS-DRG.
  • Learn how documentation impacts the MS-DRG.
  • Enforce communication between coders and physicians through a continuous internal educational process.
  • Design and develop documentation and coding monitoring forms.
  • Measure the progress and quality of the program.
  • Learn the value of working with other departments.

For those who are implementing their own program, we also offer a 40 hour CDI Boot Camp. 

Documentation Solutions, LLC ::: PO Box 634, Dearborn Heights, MI  48127-0634 ::: 734-838-0234