Clinical Documentation Integrity Spec

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Clinical Documentation Integrity Specialists improve the overall quality and completeness of the medical record. Through concurrent interaction with physicians, nursing staff, case management, and medical records coding staff/compliance specialists, they facilitate modifications to clinical documentation to ensure accurate depiction of the level of clinical services, reason for admission, patient severity, risk of mortality, and conditions present on admission. Reviews the quality of medical record documentation and conveys deficiencies to house staff and the attending physician.

Compiles and documents chart findings in the dedicated CDI database on a daily basis. Communicates with and educates members of the patient care team (physicians, advanced practice providers, patient resource managers, and case management) on an ongoing basis. Participates in select committees and provides education programs as necessary.

Reviews clinical documentation and facilitates modifications, as needed, to ensure that documentation accurately reflects the reason for admission, intensity of service rendered, risk of mortality, and conditions present on admission for all patients, in compliance with government and other regulations. Maintains a system to identify admissions for chart review. Initiates chart review within 24-48 hours of identification. Monitors the reviewed medical record every 48 hours to determine compliance with established documentation standards.

Notifies the attending physician and house staff officers or other disciplines promptly of chart deficiencies requiring clarification, with a preference for face‑to‑face communication when practical. Conducts follow‑up reviews to ensure points of clarification have been addressed/recorded in the medical record and maintains an ongoing record of the results of each chart review, including responses to each intervention.

Serves as a resource to physicians and other members of the healthcare team in matters relating to published DRG, SOI/ROM, ICD‑9, ICD‑10, and PCS information. Maintains a level of practice demonstrating knowledge and understanding of the AHIMA Practice Brief and knowledge of compliance and regulatory agency expectations. Compiles and provides timely entry to the CDI database for statistical reporting. Assists as necessary with review of the medical record post‑discharge to determine coding status.

Completes timely retrospective review for unanswered concurrent queries ("No Response" queries).

Reconciles DRG discrepancies collaboratively with the HIM team to ensure an accurate compilation of codes sent to fiscal intermediary. Maintains awareness of post‑discharge charts being held for completion of documentation deficiencies by the CDI department and is educated about the effect such charts have on Accounts Receivable work (DNFB). Maintains a consistent plan for follow‑up and completion on such charts. Facilitates ongoing education of staff in chart documentation improvement techniques and…