The American Health Information Management Association published its Clinical Documentation Improvement Toolkit last week. The 41-page document offers sample job descriptions for CDI specialists and related physician advisers, provides definitions for documentation clarifications and sample queries, and provides guidance for how to measure CDI success.
It terms of who the association considers qualified for the role, the toolkit suggests that HIM, physicians, nurses, and others with clinical or coding background make good candidates. It says that depending on the needs of the organization CDI programs can employ all RNs, all coders, or a mixture of both.
It highlights the skill-set for CDI as knowledge of payment systems and methodologies, ICD-9-CM coding concepts and guidelines, and healthcare regulatory compliance. It also points to the need for CDI professionals to exhibit strong communication skills, both written and verbal, to ensure program success.
The toolkit includes six sample policies and procedures to help provide some structure to CDI programs and offers an example of how a CDI team may chose to organize its day-to-day processes.
The toolkit is the compendium of more than a year’s worth of work by a collaboration of some two dozen professionals including ACDIS Board Members Gloryanne Bryant, RHIA, CCS, CCDS, Bill Haik, MD, FCC, Robin Holmes, MSN, RN, CCDS, and Gail Marini, MM, RN, CCS, CCDS.
Read an interview regarding the release with Bryant and ACDIS Director Brian Murphy in the CDI Strategies Archives. ACDIS will examine the implication of the AHIMA toolkit and its related releases in the July edition of the CDI Journal and during sessions at the upcoming ACDIS National Conference in Chicago in June.
The AHIMA Clinical Documentation Improvement Toolkit is available free, and can be downloaded at the AHIMA Web site www.ahima.org, under the HIM Resources tab, Practice Briefs/Toolkits, and scrolling to the bottom of the page.