A Physician-First Approach to Clinical Documentation Improvement

The CDI team works to improve accuracy on an ongoing basis. For example, it reviews charts that were flagged by Medicare RAC (recovery audit contractor) auditors for medical necessity. “We review those charts and assess if we touched the patient, and ultimately want to know if we could have done something additional to avoid the RAC audit,” says Palma.

And as ICD-10 comes bearing down, Chicoye says Baptist Health is ramping up its preparations. “We have a separate vendor that trains our CDI specialists, and assists with the coordination of all the various moving pieces within our hospital system for ICD-10, including IT, which is obviously a huge component. We’re also doing dual coding for ICD-10 as we speak. Around the country, some smaller hospitals don’t have the ability to pay for outside sourcing when it comes to these types of things, but when ICD-10 comes crashing in, we think we’ll be riding the wave pretty easily.”