AHIMA CDIP - Certified Documentation Integrity Practitioner

Patient identification and demographic accuracy is the process of ensuring that the patient’s identity and personal information are correctly recorded and verified in the health record and other systems. A potential breach of this process could result in automated registration entries that generate erroneous patient identification, which could lead to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit2

Authorship integrity is the process of ensuring that the source and content of the health record are authentic, accurate, complete, and consistent. Documentation integrity is the process of ensuring that the health record reflects the patient’s clinical status, treatment, and outcomes. Auditing integrity is the process of ensuring that the health record is reviewed and monitored for compliance, quality, and improvement purposes2

1: https://www.ahima.org/media/owmhxbv1/cdip_contentoutline_2023_final.pdf  2: https://my.ahima.org/store/product?id=67077

Proposed changes to the inpatient prospective payment system (IPPS) take effect on October 1 of each fiscal year (FY), which begins on October 1 and ends on September 30 of the next calendar year. The IPPS final rule is usually issued by the Centers for Medicare & Medicaid Services (CMS) around August 1 of each year, and it updates the Medicare payment policies and rates for acute care hospitals and long-term care hospitals for the upcoming FY. The effective date of the final rule is October 1, unless otherwise specified by CMS 2.

References: 1: Inpatient Prospective Payment System (IPPS) 2023 Final Rule Summary of … 3 2: Acute Inpatient PPS | CMS 1

A CC/MCC capture rate is a metric that measures the percentage of cases that have at least one complication or comorbidity (CC) or major complication or comorbidity (MCC) coded in the medical record. This metric is important for a CDI program because CCs and MCCs affect the severity of illness, risk of mortality, and reimbursement of the cases under the Medicare Severity-Diagnosis Related Group (MS-DRG) system. A higher CC/MCC capture rate indicates a more accurate and complete documentation of the patient’s condition and the resources used to treat them. A CDI program can use this metric to monitor the effectiveness of its queries, education, and feedback to the providers and coders. A CDI program can also compare its CC/MCC capture rate with national or regional benchmarks to identify areas of improvement or best practices 2.

References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 3 2: The Natural History of CDI Programs: A Metric-Based Model 4

The best place for the provider to document a query response is the next progress note and the problem list because this ensures that the query response is timely, consistent, and integrated into the health record. According to the AHIMA/ACDIS query practice brief1, the provider should document the query response in the health record as soon as possible after receiving the query, preferably in the next progress note. The provider should also update the problem list to reflect any new or revised diagnoses resulting from the query response. This helps to maintain an accurate and comprehensive list of the patient’s current and chronic conditions, which can facilitate continuity of care, quality reporting, and reimbursement. Documenting the query response in an addendum to the history and physical or only on the query form is not sufficient, as it may not capture the current status of the patient or be easily accessible to other providers or coders.

References:

CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)

Guidelines for Achieving a Compliant Query Practice—2022 Update1

A primary step for the CDIP to promote the CDI program throughout a major hospital is to determine the primary interests of an individual or department that could benefit from or support the CDI program. This is because different stakeholders may have different motivations, expectations, and challenges related to CDI, and the CDIP should tailor the communication and education strategies accordingly. For example, physicians may be interested in how CDI can improve their quality metrics, reimbursement, and patient outcomes; coders may be interested in how CDI can reduce coding errors, denials, and queries; and executives may be interested in how CDI can enhance revenue integrity, compliance, and reputation. By identifying the primary interests of each individual or department, the CDIP can demonstrate the value and relevance of the CDI program, address any barriers or concerns, and foster collaboration and engagement 23.

References: 1: AHIMA CDIP Exam Prep, Fourth Edition, p. 133 4 2: How to Promote Your Clinical Documentation Improvement Program 3: How to Market Your Clinical Documentation Improvement Program

A query is noncompliant if it includes options that are not supported by the clinical indicators or the patient’s condition. In this case, hypernatremia is a condition of high sodium level, not low sodium level, and it is not consistent with the treatment of 0.9% saline IV. Therefore, it is a clinically irrelevant option that may confuse or mislead the provider. A compliant query should only include options that are reasonable and plausible based on the available documentation and evidence. (CDIP Exam Preparation Guide)

References:

CDIP Exam Content Outline1

CDIP Exam Preparation Guide2

AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice3

A query should include relevant clinical indicators from the health record that support the need for clarification and the query options. Clinical indicators are objective and measurable signs, symptoms, laboratory results, diagnostic test results, medications, treatments, and other documented findings that are related to a specific diagnosis or condition. Information from previous encounters, the impact on quality, and the impact of reimbursement are not appropriate to include in a query, as they may introduce bias, lead the provider, or imply a desired response.