Basics of Clinical Documentation Improvement

CDI stands for Clinical Documentation Improvement, a specialist which play a vital role in healthcare system. CDI along with coders can help a lot in improving the documentation and accurate coding of medical charts. CDI specialist are typically registered nurses. They carry a Certified Clinical Documentation Specialist (CCDS) credential as well. The main job of the CDI specialist is to educate the physician to improve the documentation for patient care and safety.
Inaccurate, missed, improper or unclear documentation directly affects the risk adjustment and Hierarchical condition categories (HCC).

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What is HCC and Risk Adustment Factor (RAF) Score

The Hierarchical Condition Category (HCC) risk adjustment model is used by CMS to estimate predicted costs for Medicare beneficiaries, and the results directly impact the reimbursement healthcare organizations receive for patients enrolled in a Medicare Advantage plan.

CMS requires that all qualifying conditions be identified each year by provider organizations. Documentation that is linked to a non-specific diagnosis, as well as incomplete documentation, negatively affects reimbursement.

The HCC risk adjustment model assigns a risk score, called the Risk Adjustment Factor (RAF), to each patient as a relative measure of the probable costs of care for the individual patient. The RAF score is used to adjust capitation payments for beneficiaries enrolled in Medicare Advantage plans and some demonstration projects

Each HCC has an associated value called the relative factor, like the relative weights that are used in DRG classification systems

These relative factors contribute to the patient’s RAF. An individual may have zero, one, or multiple HCCs that impact the RAF score that is calculated each calendar year.

For example:
HCC 9 Relative Factor-0.973
HCC 10 Relative Factor- 0.672

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Importance of Clinical Documentation Improvement (CDI) specialist

In inpatient setting, the CDI helps in keep the accurate and specific documentation about patient status. While the patient in the hospital, CDI specialist regularly review the documentation of patient’s chart to be sure it reflects an accurate clinical picture of the severity of illness for the patient, for quality measures, for specificity and to query the physicians for clarification when necessary.

The clear documentation helps the medical coders to give more specific codes for the procedure and diagnosis.

The staff of CDI specialist is less; hence they cannot review each and every patient’s chart. So, only top volume diagnosis-related groups (DRGs), surgical DRGs, DRGs for quality measures, speciality, specific principal diagnosis selection etc. are reviewed by CDI

In inpatient setting, both the CDI specialist and coder assign codes to reach out to the final DRG based on the principle diagnosis, principle procedure and diagnoses that are complication and comorbities (CCs) or major complications and comorbidities(MCCs).

A CDI specialist’s DRG is considered a working DRG (meaning: the patient is still “in house). The coder’s DRG is in the final DRG (meaning: after the patient has been discharged).

The medical coder helps the CDI specialist to understand the coding guidelines and determination that affects coding. For example, a combined code can have a different effect on the DRG than coding each diagnosis individually. Similarly, CDI specialist also helps medical coders to understand the clinical notes, laboratory test, and patient’s medical chart to make sure the coding is reflective of the clinical picture of the stay.

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MisMatch DRG

 If the Clinical Documentation Improvement or CDI specialist and coder does not end with the same DRG, it’s considered a DRG mismatch. The situation requires the CDI specialist and coder to have open and effective communication about the differences in the pre-diagnosis procedure, CC/MCC etc.
This mismatch DRG can even lead to query the physician if the patient has already been discharged.

References:

https://acdis.org/certification

https://study.com/articles/How_to_Become_a_Clinical_Documentation_Specialist.html

https://www.americannursetoday.com/rewarding-role-clinical-documentation