CDI: Why Compliance Must be at the Top of Everyone’s List: Part II

AI-powered solutions must align with applicable coding guidelines.

Electronic health records (EHRs), clinical documentation software, and enabling technologies are working together in new and exciting ways to create accurate, robust, and concurrent patient documentation that improves quality of care while protecting healthcare organizations’ financial integrity.

But as I wrote last Tuesday in Part I of this series, compliance remains at the top of everyone’s list, and for good reason.

Because they’re bolstered by machine learning, deep domain knowledge, and vast amounts of health data, technologies powered by artificial intelligence (AI) can and do make physicians and clinical documentation improvement (CDI) professionals more accurate and efficient.

To support organizations in their compliance efforts, however, these same technologies must be evidence-based and work in accordance with applicable laws and coding guidelines – all under the umbrella of an advanced practice CDI program.

Advanced-practice CDI programs enable collaboration between the CDI team, physicians, and professional coders to create the most precise and accurate final coding. At the heart of these programs are the CDI professionals who combine extensive clinical expertise, patient care experience, and astute regulatory knowledge with the applicable organizational policies and procedures to improve coding compliance while also preventing costly denials.

Compliance best practices include oversight and monitoring to safeguard CDI processes

Advanced-practice CDI professionals safeguard the compliance of CDI processes through a range of accepted best practices that include oversight and monitoring. For example, relative to computer-assisted physician documentation (CAPD) clarifications, CDI professionals provide complete transparency and audit reports that include not just the physician responses, but also the sources of clinical evidence that support final diagnosis and coding.

Throughout the entire CDI workflow, avoiding “leading” queries is essential. That is, advanced-practice CDI professionals will only offer recommendations that are highly consistent with available, documented evidence; otherwise, these queries may “lead” a physician to a particular potentially problematic conclusion.

CDI compliance oversight will also include quality reviews of clarifications to assure clinical evidence and validity, training for leadership and CDI staff on evidence-based documentation strategies, and the establishment of a multidisciplinary steering group.

At the end of the day, advanced-practice CDI programs that rely on compliant, best-practice driven queries create a great deal of value for the entire health system, from the patient to the provider and the hospital.

CDI professionals at the center of these programs combine their expertise and experience with AI-driven solutions that support clinical decision-making, streamline access to evidence-based content, and create a collaborative, closed-loop, compliant program.