CDI: Lighten the Load for Physicians

Customize communication to help your practice meet CDI goals and objectives.

By Stephanie Cecchini, CPC, CEMC, CHISP
Clinical documentation improvement (CDI) has become a hot topic, especially as we gear up for ICD-10. The goal of CDI is for providers to augment their documentation processes to collect patient care data more fully, but also succinctly. In turn, coders are better equipped to code claims accurately and to the added specificity ICD-10-CM demands; and payers have the supporting data they need to process and appropriately pay claims. As logical as this sounds, you may encounter resistance.
Physicians May Cringe at CDI
According to the Medscape® Physician Compensation Report 2012, half of all physicians spend more than five hours per week on paperwork and other administrative activities. With so much effort devoted to non-clinical requirements and regulations, nearly half (46 percent) of physicians also say that if given another chance, they would not choose medicine as a career. For many providers, it’s simply too hard to “buy in” when they see no correlation between the semantics required for medical documentation data elements and their true purpose in patient care.
To complicate matters, CDI education requires much more than subject matter expertise; it requires truly effective communication. Without a physician’s buy-in, education is a very difficult objective to meet. Communication barriers between coders and physicians often create difficult and opposing points of interest. How, then, can a practice meet CDI goals and objectives?
Customize Communication
Make learning less of a chore for your physician by using a customized approach to communication. For example, a physician is more likely to listen and respond to communication that is succinct and based on fact. This may require a CDI expert and documentation assessment.
Coders are often excellent communicators for CDI issues because they understand both the mindset of the physician and documentation requirements. The person selected to conduct CDI education must be an expert at both documentation assessment and communication. A documentation assessment allows the CDI expert to see where deficiencies exist, and tailor training to match the physician’s unique learning style. A physician’s medical specialty also plays a big part in narrowing the learning curve. For example, an orthopaedic surgeon doesn’t need to learn documentation requirements for trimester notations in obstetrics care; nor do cardiologists need to know the requirements for documenting open fractures according to Gustilo classification.
If there are no coders in your practice who meet the qualifications, consider CDI outsourcing to help providers navigate complex documentation requirements. Analyze your practice to select the right CDI partner. The best partners are leaders who are capable of effective planning and producing quality deliverables. Practices that select CDI consultants based on their evaluation of a firm’s reputation, experience, and service philosophy will have the best results.
Stephanie Cecchini, CPC, CEMC, CHISP, is an ICD-10 trainer and member of the Salt Lake City, Utah, local chapter. She can be reached at (801) 664-3639.


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Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.

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