Clinical documentation improvement (CDI) efforts are at the center of healthcare today. These programs provide guidance through a sea of regulations and fraud and abuse prevention activities as well as the processes of accurately assigning classification codes and providing accurate quality reports. CDI is the bridge that connects clinical care providers to both coding professionals and external resources such as Centers for Medicare and Medicaid (CMS) quality reports.
The newly updated AHIMA Clinical Documentation Improvement Toolkit provides guidance on developing and maintaining a structured CDI program. This toolkit underwent its third revision in 2016, with updates to reflect changes in documentation requirements, metrics for success, the role of the physician advisor, starting a CDI program, and hiring the right individuals. In addition, the toolkit includes important information regarding the use of secondary coded data that affects quality measures and third-party audits.
The toolkit includes multiple appendices including sample job descriptions, checklist for orientation, 90-day evaluation form, pre-hire assessment, key monthly metric reports, graphs, and query monitoring samples.