to the digital edition of Advantage
How to Use the Digital Edition of AHIMA Advantage
Magnify it! Use the magnifying glass to zoom in.
Use the slide zoom tool to set the same magnification for all pages.
Share it! E-mail articles to colleagues, post them to
Facebook, and Tweet them.
Search it! Search for keywords throughout
the entire issue—and all back issues.
Download it! Save a copy to your computer.
Print it! Print stories or single pages.
Remember, you can always access tips and help
from the “Help” tab in the menu tray on the left.
Welcome to the June 2012 issue of AHIMA Advantage. This
video clip is an summary of the 2012 Hill Day event. See page 7
for a complete wrap up of the event.
HIM: At the Core of CDI
The purpose of a clinical documentation improvement (CDI) program
is to initiate concurrent and, as appropriate, retrospective reviews of
health records for conflicting, incomplete, or nonspecific provider
documentation. Ultimately, the goal is to identify clinical indicators
to ensure the diagnoses and procedures are supported with
appropriate ICD-9-CM codes (soon to be ICD-10-CM/PCS codes).
A FOUNDATION FOR
QUALIT Y CARE
• Accurate and appropriate reimbursement for services provided
In addition, precise, thorough clinical documentation provides a defense for
regulatory compliance reviews, including Recovery Audit Contractors (RAC)
and Medicaid Integrity Contractors (MIC).
Effective CDI efforts require in-depth knowledge of documentation requirements,
coding classification standards and guidelines, and reporting requirements. An
understanding of clinical records is also necessary. AHIMA offers a robust portfolio of
resources to support CDI practitioners in these initiatives.
Learn more inside about AHIMA’s CDI Resources!
Quality clinical documentation in a health record is vital
to the patient, physician, and healthcare facility, and
provides a foundation for quality care.
Documentation improvement programs were formed in an effort to work
with care providers to appropriately reflect the quality of patient care while
increasing accuracy in coding and reporting. Health information management
(HIM) and clinical staff form the core of CDI programs working within a
multidisciplinary team to provide guidance on documentation challenges.
A CDI program offers many advantages for a healthcare facility, including:
• More clearly identifying the risk of mortality and severity of illness
• Improved outcomes data
Guard Privacy and