I am thrilled to welcome Dr. Maria Mirt to the latest episode of the No Fears CDI Podcast! Maria joins us at the fascinating crossroads of primary care, operations, and clinical documentation integrity (CDI). Her insights are both practical and inspiring, especially for clinicians and practice leaders navigating today’s documentation demands.

Clinical documentation improvement has evolved over the last ten years with the advent of the electronic health record and the ability to use natural language processing and other key software to enhance the overall efficiencies and effectiveness of medical record chart reviews. This facilitates the identification of opportunities for diagnoses reporting, hospital acquired conditions and patient safety indicator clarifications. As a whole the profession has not kept up

Just like a roadmap or if you use a map direction app such as MapQuest or Waze, one needs a start and end point. The same principle or concept applies to the medical record. There is a definite starting and ending point for a medical record, whether inpatient, observation, office visit, or ED to name just a few settings. Let’s focus upon hospitalization…More than half of patients are admitted to the hospital from the ED so that for all intents and purposes is the starting point.

Listen to Glenn cover various points in the CDI arena. You can check out the website this podcast is featured on here.

Most Clinical Documentation Integrity (CDI) programs are mislabeled and misidentified in the present format. Integrity is defined as the quality or state of being complete or undivided per Merriam-Webster. A few years back the association representing the Clinical Documentation Improvement Specialist’s community elected to replace the “Improvement” part of the name to “Integrity”, now referred to as Clinical Documentation Integrity Specialists.

The use of case-mix as a proxy for judging the effectiveness of clinical documentation improvement programs can be characterized as an unreliable imprecise measure of overall success. While case-mix over time can potentially increase over time as clinical specificity in diagnoses capture improves, there are a myriad of contributing factors that control the ultimate calculation of case-mix. Attributing improvement in documentation to increases and fluctuations

As many of you are aware, I have been advocating passionately for a total transformation of current CDI processes that have virtually remained stagnant for the past twelve plus years. This transformation in CDI requires a two-pronged approach to be successful in execution, the first consisting of rebranding and reformulation of current CDI processes that have demonstrated over time to be ineffective in achieving any meaningful, measurable, sustainable improvement

What many CFOs are being told: “Clinical validation denials and DRG downgrades are the result of egregious, overaggressive payers who ignore official coding guidelines and arbitrarily challenge diagnoses like sepsis, acute respiratory failure, and metabolic encephalopathy.”

A major challenge of current clinical documentation improvement processes is the undivided focus upon reimbursement as the primary outcome, something undisputable with a clear review of present day Key Performance Indicators. The expression and reporting of the clinical truth in the record beginning with the Emergency Room Documentation, transitioning into the H & P and continuing with the consultant reports and progress notes culminating in the discharge summary

Most Clinical Documentation Integrity (CDI) programs are mislabeled and misidentified in the present format. Integrity is defined as the quality or state of being complete or undivided per Merriam-Webster. A few years back the association representing the Clinical Documentation Improvement Specialist’s community elected to replace the “Improvement” part of the name to “Integrity”, now referred to as Clinical Documentation Integrity Specialists.