AHIMA Brief Provides Guidance for Clinical Documentation Improvement Programs

A new practice brief in the May issue of the Journal of American Health Information Management Association notes that the focus of most CDI programs is to improve the quality of clinical documentation regardless of its impact on revenue, while facilitating accurate representation of healthcare services through complete and accurate reporting of diagnoses and procedures, according to an AHIMA news release.

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This practice brief provides an overview of key elements in establishing, maintaining or enhancing a CDI program, which can be accomplished through various methods and a structure that are tailored to the unique needs of a healthcare entity, according to the release.

This article includes a sidebar that lists the people who typically fill CDI roles: HIM professionals, nurses, physicians and other healthcare professionals with a clinical or coding background. It also highlights how organizations can staff their CDI programs using one of two general program models — single discipline models and hybrid models.

The article also provides templates and checklists for handling queries and developing policies and procedures.

Read the AHIMA’s release about CDI programs (pdf).

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