Clinical Documentation Improvement

ACS does not have a “one size fits all” approach to CDI.  We believe that there should be an assessment of the expertise, interests, and workload of the staff in each hospital in order to find the “best fit” for the CDI program.  The objective should be to establish a documentation improvement process that functions collaboratively with documentation improvement profesionals, physicians and coders.

Our consultative approach includes the following steps:

  • Organizational assessment for CDI readiness:  Extensive data analysis, chart review and process analysis to identify hospital-specific needs for documentation improvement, staffing, and process improvement;

  • CDI Focus education for CDI staff, coders, and medical staff with initial classroom style training and case studies, supported by e-learning lessons for review and re-education;

  • Side-by-side training with CDI specialists on patient care units;

  • Development of a CDI leadership team to assure ongoing monitoring and program effectiveness;

  • Periodic reassessment of data, coding accuracy and documentation adequacy with adjustment of CDI goals as the program matures.

The CDI FOCUS program developed by Administrative Consultant Service takes the complexities of the Medicare Inpatient Prospective Payment System and narrows the focus to allow your staff to concentrate on key indicators for coding accuracy and documentation adequacy. The CDI FOCUS program includes a combination of educational tools, staff training, software references and benchmarking data.

Foundations for Success:

CDI Handbook for coders, clinical documentation improvement specialists and case managers includes case studies and important coding validation references as well as links to important core quality measures.

Classroom style training introduces new material in a modular approach. The modular approach delivers new content in manageable pieces with minimal disruption of your daily routine. Specialized training sessions are recommended for coders, clinical documentation improvement specialists and case managers as well as physicians and physician extenders.

One-on-one Interaction:

Individualized training is performed on the nursing units with clinical documentation improvement specialists, case managers and physicians to enable them to apply key CDI principles to current cases.

Concurrent Review Tools:

CDI FOCUS software and unit-specific Focus Lists to permit clinical documentation improvement specialists and case managers to effectively review concurrent documentation without having to first assign ICD-9-CM diagnostic and procedure codes.  For a demo on the CDI Focus software click play ->

Understand Query Issues:

Query forms and electronic tools to log and track query trends by physician, DRG, or query type.

Scorecards:

Benchmarking data to monitor CDI improvements from month-to-month. This easy-to-follow, color-coded scorecard allows you to quickly determine DRGs in need of focused review.