Clinical Documentation Specialists Can be Sturdy RAC Defense

While the new category of clinical documentation improvement specialist started before recovery audit contractors came on the scene, CDI specialists can help hospitals guard against RAC recoupment, says Ernie de los Santos, chief information officer for eduTrax.

As RACs expand their activities, "there is an increasing need for physicians to document their work precisely in the chart, so that the documentation supports the claim," Mr. de los Santos says. "But physicians often don't have the time to keep up with all the changes in coding. They have enough on their hands just providing clinical care."

Enter, the CDI specialist, whose numbers have been growing fast. "The CDI specialist is a bridge between the physician and the coder," Mr. de los Santos says. "They bring together clinical and coding knowledge and are able to teach complex topics to clinicians."

The work involves specialized training and there now is an Association of Clinical Documentation Improvement Specialists.

What they do
CDI specialists review documentation in the hospital medical record during the patient’s stay. Keeping tabs on the patient’s clinical status, they review the record for accuracy and specificity of diagnostic terminology. When the documentation is missing or is vague, they query physicians for further information.

CDI specialists also work closely with coding staff to ensure the discharge diagnoses and coexisting comorbidities completely portray the patient's clinical status and care.  Many such specialists also provide educational sessions for physicians, nurses and other clinical staff on documentation improvement.

Hospitals initially hired CDI specialists to try to make sure all necessary codes are included in the chart, so no money was lost, but Mr. de los Santos predicts these specialists will become even more valuable with RACs and the advent of ICD-10 diagnosis codes in October 2013. "With ICD-10, much more detail will be needed in the chart," Mr. Santos says.

Learn more about eduTrax.

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