Clinical documentation improvement efforts have expanded well beyond the initial CMI index focus. Clear and concise documentation also ensures optimal severity of illness (SOI), risk of mortality (ROM), and can assist in several CMS quality programs. But how effectively are CDI professionals assisting with these documentation improvement efforts? Under a recent debate through LinkedIn by Glenn Krauss, was the question of effectiveness for a remote CDI professional with no actual physician contact other than an electronic query for clarification. He stated the robotic generation of queries to a physician without improvement in their subsequent documentation is not a measure of success. It would be difficult to deny this statement. However, in the absence of a face-to-face educational opportunity, query writing can be performed with this educational goal in mind. The actual reason the clarification is sought can and should be explained clearly to the physician through the query. Physician queries can be a powerful communicative tool. The burden of proof is on the physician to document each diagnosis to the greatest specificity possible for accurate coding of the condition. Strong clinical indicators within the query assist the physician in making that diagnosis determination.

http://journal.ahima.org/2017/02/24/the-key-to-a-top-notch-clinical-documentation-program/
http://journal.ahima.org/2013/02/01/physician-query-examples/

Written by Barb Brant, MPA RN CDIP CCDS CCS