Clinical Documentation Integrity

This CDI Toolkit for New Leaders will address the various topics that will aid leaders in proactively addressing the unique challenges the come along with focusing on the success and sustainability of a CDI Department. Whether aspiring to move into a management role or looking for ways to further increase your current leadership skillset, the intent of this toolkit is to provide a foundational knowledge base to address common CDI leadership challenges. 

The goal of this Prospective CDI Reviews and Query Alert Practice Best Standards is to provide best practices relating to prospective reviews and to recognize that there is a difference between documentation alerts/notifications designed to influence a provider’s documentation versus a clinical alert/notification for clinical decision making at the time of charting by a provider. In most instances, these terms may be used interchangeably without realizing that they are two very different things.

The Inpatient Query Toolkit benefits the hospital’s compliance with billing/coding rules and serves as an educational tool for providers, CDI professionals, and coding professionals. Proper responses to queries result in improved accuracy and completeness in documentation, coding, reimbursement, as well as severity of illness (SOI) and risk of mortality (ROM) classifications.

As healthcare continues to evolve with a stronger focus on containing the costs of quality care across the continuum of care, CDI and the art of querying are now expanding beyond the inpatient setting to include hospital outpatient clinics, physician clinics, emergency departments, ambulatory surgery centers, hospital observation, and other outpatient care settings. Therefore, providers across the healthcare spectrum need to be educated about the importance of documentation improvement through AHIMA Outpatient Query Toolkit.

A CDI toolkit is useful not only to the professionals who work in CDI but also helpful to physicians, hospital administrators, health information management (HIM) professionals, nursing staff, and others in a variety of healthcare setting. This beginner's toolkit will benefit those professionals who are new to CDI. 

A CDI toolkit is useful not only to the professionals who work in CDI but also helpful to physicians, hospital administrators, health information management (HIM) professionals, nursing staff, and others in a variety of healthcare setting.

The industry gold-standard AHIMA/ACDIS practice brief provides best practices for professionals in all healthcare settings who participate in query processes.

Boost Workflow Efficiency, Accelerate Proper Reimbursement, and Ensure Compliance with AHIMA CDI Query Templates

Unlock the power of electronic, standardized provider query templates designed to work with leading EHR systems. Complete the form to see the list of more than 180 templates available across inpatient, outpatient, long-term care, and pediatric settings.

Improve Accuracy, Consistency, and Collaboration in Clinical Validation. Download the practice brief.

This Practice Brief can be used to walk through various diagnosis and procedure considerations to assist organizations in developing robust facility-specific coding guidelines. It includes basic guidance as well as insights into the preparation and decision-making process.

This Practice Brief is focused on the key performance indicators (KPIs) that can be evaluated to measure the performance of clinical documentation integrity (CDI). KPIs are measurements specific for an organization or department being evaluated. KPIs are critical to track progress toward an intended result.

The AHIMA Ethical Standards for Clinical Documentation Integrity Professionals are intended to assist in decision making processes and actions, outline expectations for making ethical decisions in the workplace, and demonstrate the professionals' commitment to integrity. 

The clinical validation process has become a very challenging task for most healthcare organizations, so it is important that each organization uses industry guidance to create their own policy and procedure related to the clinical validation process in both the inpatient and outpatient settings.

The discipline of clinical documentation integrity (CDI), whether practiced by clinicians or coding professionals, has the potential to deliver great value to the healthcare system—including to the patient, who deserves a clear, concise, consistent, and accurate health record to support continuity of care.

This Practice Brief will outline the benefits of the CDIP credential to assure organizations and providers that their CDIP-credentialed staff are working to ensure clinical information supports clinical care, treatment, coding guidelines, and reimbursement methodologies.

This Practice Brief discusses the impact of physician engagement on clinical documentation integrity programs.

This Practice Brief will explore some of the benefits and challenges of scribes within the physician practice setting.