Starting with a Solid Foundation

Author: Autumn Reiter – Live notes from CHIA 2019, Tuesday, June 11


One statistic that caught our attention from the ACDIS 2018 CDI Week Industry Overview Survey hit on those who are now reviewing outpatient or ambulatory records within their CDI programs. 53.20% of the annual survey respondents noted their programs are reviewing these record types. This single statistic speaks to the ever-growing role Clinical Documentation Improvement professionals play in our industry. Expansion beyond our historic roots covering Inpatient Medicare patients is now more prevalent than ever!


However, as the TrustHCS CDI team continues to meet with CDI leaders, we know there are still programs looking to take some of the more initial steps of expand to all-payer inpatient coverage. We have engaged with groups to help them make these expansion dreams a reality and, in doing so, have found some foundational steps that we always advise taking before any program expansion takes place.


Whether your CDI program expansion includes moving to all-payers, ambulatory, or outpatient; here are some critical foundational items to address first.


  1. Revamp Policies and Procedures

What are the query policies your CDI specialists need to follow? What expectations have been set with your providers on the responses and turnaround time needed from queries? These items and many others need to be covered within your program’s policies and procedures. It is also wise to revisit these key program components on an established recurring timeline. Changes in technology, staff, and expansion of program coverage often lead to necessary changes to policy and procedure followed by communication of changes to all applicable parties.


  1. Perform Quality Assurance Reviews

The adage “you can’t manage what you don’t measure” will always hold true. When it comes to CDI the quality related to following query policies is important to monitor. As program expansion is considered, the establishment and ongoing delivery of quality assurance findings is important to help ensure new program focus is adhering to policies and procedure.


  1. Create Productivity Accountability

Outside of monitoring adherence to query policies, our Clinical Documentation Improvement staff should have expectations set for the number of reviews they complete within a set timeframe. While most programs set standards at hourly increments, if an expectation is set within some measurable timeframe this critical program building block will serve its purpose. Remember, this is another area that must be measured and monitored to help know when to engage a CDI specialist about why productivity isn’t being met.


  1. Standardize Queries

It should go without saying that query standardization is a necessary foundational item for programs. However, with so much being managed and put on our plate as CDI professionals, this is one area the TrustHCS team has seen lack for more established programs. As with program policies and procedures, query templates should be reviewed on a recurring schedule. Standardization of queries is not a one-time effort. It takes regular review to deploy necessary modifications to assist with response rates and to ensure responses are providing the proper feedback for our CDI teams. With an expectations of query standardization and a process to review these queries, program expansion can hit some serious barriers to success quickly.



Whether you are part of the 53.20% of CDI programs reviewing outpatient and ambulatory records or you’re still considering expansion into all-payers; keeping these foundational elements top of mind and part of your plans will only help improve your CDI efforts. You can also learn more about one facility whose expansion of CDI mean serious ROI by clicking here.