Consider the principles and applications of classification systems (e.g., ICD-10

Question

Consider the principles and applications of classification systems (e.g., ICD-10, HCPCS) and medical record auditing used within a clinical documentation improvement (CDI) program. Appraise the value and challenges of a quality CDI program by defending the need for ongoing CDI program support and critique at least three (3) challenges in the CDI process. Make connections between auditing, accurate diagnostic and procedural coding with classification systems, and CDI programs. Your executive summary should reflect upon the need for CDI and best practices for ensuring compliance.

Consider the principles and applications of classification systems (e.g., ICD-10, HCPCS) and medical record auditing used within a clinical documentation improvement (CDI) program. Appraise the value and challenges of a quality CDI program by defending the need for ongoing CDI program support and critique at least three (3) challenges in the CDI process. Make connections between auditing, accurate diagnostic and procedural coding with classification systems, and CDI programs. Your executive summary should reflect upon the need for CDI and best practices for ensuring compliance.

Explanation / Answer

The principles and applications of classification systems (e.g., ICD-10, HCPCS) and medical record auditing used within a clinical documentation improvement (CDI) program is
* ICD-10 (International classification of diseases, tenth edition) codes provide more detailed information for measuring quality, safety and efficacy of health care service.These codes helps to note diseases on health records , and tracks epidemiological trends .They also assist in medical reimbursement decisions.
*HCPCS( Healthcare Common Procedure Coding System) is a coding system used to identify products, supplies and services that are not included in the CPT codes. These codes represent medical procedures to Medicare, Medicaid and other third party payers while coding bills.
CDI offers a common platform for sharing the data and real-time reporting which leads to better communication between clinical teams.
The three challenges in the CDI process include
1)bridging the gap between clinical terminology used by health care providers and diagnostic coding terminology
used for reimbursement.
2) Hiring the right professionals in the CDI position , the one who has the basic knowledge of coding guidelines, one who understands the ethics and compliance issues surrounding the healthcare provider query process.
3)To focus on maintaining correct and accurate documentation during care transitions and across all healthcare
settings.
Timely auditing ,accurate diagnostic and procedural coding with classification systems helps to monitor the
work of CDI professionals and ensures highest level of integrity of CDI programs.

Clinical documentation is necessarry for complying with quality measures. As it supports coding which is the basis of correct revenue and reimbursement, provides quality information which inturn supports care management in hospitals,there is a need for CDI.

Proper examination of the documents for incomplete, ambiguous or conflicting information, physicians responding
to CDI professionals queries timely and completely, active participation from treating physicians are some of the
best practices to be followed to ensure compliance. These practices help hospitals to capture appropriate codes to
adequately reimburse for the services they provide.

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