DCBA

FAQs

Not sure why a strong Clinical Documentation Improvement Program is essential or what goes into one? Check out the following list of Frequently Asked Questions and learn why such a program can benefit your facility.

Q: What distinguishes DCBA from other Clinical Documentation Improvement Programs?

A: An effective Clinical Documentation Improvement Program is based on communication between members of the medical staff regarding the clinical aspects of the diseases being treated and the procedures being performed that results in accurate representation of the conditions and treatments in both chart documentation and ICD code assignments. This leads to appropriate measures of severity of illness and risk of mortality for physician and hospital profiles, as well as honest and ethical billing for services provided by both.

Q: What are the elements of a clinical documentation improvement program?

A: First and foremost, any clinical documentation improvement program must have as its number one objective measurable improvement in medical record documentation. What is meant by measurable improvement since the point can be argued that this measurement may be an intangible concept? The most often repeated frustration and challenge faced by medical records coding personnel is lack of specificity in physician documentation and poorly defined or missing diagnoses when reviewing the record for assignment of ICD-9 codes. Countless times coding errors are committed due to incomplete and/or nonspecific in physician documentation.

So, one means of measuring improvement in medical record documentation is to monitor the use of nonspecific ICD-9 diagnoses and procedure codes and the assignment of symptom codes. Another means of measuring documentation improvement is to track the number and types of physician "queries" still being asked concurrently and retrospectively.

The basis for measuring improvement in medical record documentation should not be increase in Case Mix Index (CMI), but improvement in severity of illness an risk of mortality scores as determined by external profiling agencies, such as University Health System Consortium (UHC), other public reporting agencies and APR DRGs.

Q: How involved should coding staff be?

A: An effective documentation improvement program goes beyond simply training the documentation specialists. The coding staff must be considered as an integral part of any documentation improvement program and afforded the opportunity to participate in the program. Coder participation does not imply "casual once over" training reflecting principles of coding but instead incorporates clinical educational training.
The coders should be included and in attendance at all relevant clinical training scheduled for the documentation specialists.

Aside from fostering a learning environment for the coders, the coders will hear the same message the clinical documentation specialists are hearing, laying the foundation for creating a strong teamwork infrastructure. A successful documentation improvement program embraces input and efforts from the documentation specialists as well as the coders

Q: How do we bridge the gap between the documentation team and the coding team?

A: In any documentation improvement program, the means to the end is just as important as the end point. By including the coders in the documentation improvement educational training from the onset, the processes necessary to impact documentation become the center of attention. Fostering discussions between CDI and coding staff aids in an understanding of the complexities of each other's professions providing a more seamless transition from the concurrent to the retrospective milieu.
Practically speaking, for those organizations that choose to have the CDS assign a working DRG, the focus upon measuring the congruence between the DRG assigned by the coder versus the DRG assigned by documentation specialists detracts from the goals of any documentation improvement program, mainly affecting positive change in physician documentation behavior. Concentrating upon DRG congruence may create an adversarial relationship between the coding staff and the documentation specialists, pitting the coder against the documentation specialists and vice versa. The documentation improvement process suffers in the sense the documentation specialist's efforts are geared toward securing the "correct DRG" as opposed to clarifying unclear, incompletely documented clinical conditions and translating the physician's implicit thought processes into explicit physician medical record documentation.