CDI Workbook: Investigating Complex Cases and Formulating Queries

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CDI Workbook: Investigating Complex Cases and Formulating Queries

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CDI Workbook: Investigating Complex Cases and Formulating Queries

Sheila Duhon, MBA, RN, CCDS, A-CCRN

Reviewing cases and formulating queries is the central work of a clinical documentation improvement (CDI) professional. However, different chart and different review focus change the way a CDI specialist conducts their review.

CDI Workbook: Investigating Complex Cases and Formulating Queries provides CDI professionals, at all levels, with the practical tools and tips needed to hone their CDI reviews and skills. Readers will walk through in-depth case scenarios with author Sheila Duhon, covering the most frequent documentation trouble spots and examining theoretical records through the lens of different programmatic focal points. Following each case scenario, you’ll find query suggestions and discussion ideas related to why a CDI specialist would query for certain diagnoses and tips for physician CDI education.

Whether you’re reviewing for CC/MCC capture, quality measures, risk adjustment, etc., the Workbook has something to teach you.

The Workbook provides:

  • Clinical case study reviews for all levels of CDI experience
  • Advice for determining record prioritization depending on CDI program goals
  • Tips and tools for compliant query creation
  • Physician education ideas targeted for specific diagnoses
  • Tools for evaluating CDI program outcomes and CDI staff effectiveness


About the Author:

Sheila Duhon, MBA, RN, CCDS, A-CCRN, is national CDI director, educator, performance management and innovation division for Tenet Healthcare Corporation. She’s been involved in CDI since 2006, and finding the position offered a career in which she could continue her love of learning.


Published: September 2018

Page count: 148
Dimensions:8.5 x 11
ISBN: 978-1-68308-806-6

Table of Contents

About the Author
Introduction
Chapter 1: Core CDI Program Practice and Competencies

  • Historical perspective 
  • Mission statements 
  • Steering committees 
  • Organizational reporting structure 
  • Hiring and training new CDI specialists 
  • CDI medical record review process 
  • Measurements of success 
  • The value of a robust CDI program 


Chapter 2: Physician engagement and education 

  • A comprehensive team approach 
  • The CDI specialist 
  • The physician provider 
  • Engaging physicians 
  • The physician advisor 
  • The physician advisor’s role in CDI 


Chapter 3: A Compliant Query Practice 

  • Historical perspective 
  • Authoritative guidance 
    • AHIMA 
    • ACDIS 
    • HIPPA and the Four Cooperating Parties 
    • The False Claims Act and the Stark Law 
  • The query process 
  • ACDIS/AHIMS joint brief, 2016 
  • The AHIMA 6 
  • What is a leading query? 
  • What is a compliant query? 
  • Query storage and retrieval 
  • The verbal query versus the written query 
  • There’s no correct or incorrect response to a query 
  • The concurrent query process 
  • The retrospective query process 
  • When a provider refuses to respond to a query 
  • Authorized persons who can query a provider 
  • The query format 
    • Open-ended queries 
    • Multiple choice queries 
    • Yes/no queries 
  • Writing effective queries: Best practices 
    • The “TRIC” to query success 
    • The “dos” for an effective query process 
    • The “don’ts” for an effective query process 
  • Developing an effective


Chapter 4: Case Studies: Exercises in the Practical Application of the CDI Review Process and Query Development 

  • Neurology: Altered mental status 
    • Case study 
    • Sample query 
    • Discussion 
  • Hematology: Anemia 
    • Case study 
    • Sample query 
    • Discussion 
  • Cardiovascular: Heart failure 
    • Case study 
    • Sample query 
    • Discussion 
  • Nephrology: Chronic kidney disease 
    • Case study 
    • Sample query 
    • Discussion 
  • Procedure: Debridement 
    • Case study 
    • Sample query 
    • Discussion 
  • Nutritional: Malnutrition 
    • Case study 
    • Sample query 
    • Discussion 
  • Multiple conditions: Acute kidney injury, pneumonia, respiratory failure, and sepsis 
    • Case study 
    • Sample queries 
    • Discussion 
  • Multiple conditions: neoplasm, malnutrition, and renal condition 
    • Case study 
    • Sample queries 
    • Discussion 


Chapter 5: Leading and Managing a CDI Program 

  • CDI program evaluation 
  • CDI program leadership 
  • CDI program management 
  • CDI specialist development 
  • Measurement of CDI program goals 
  • The big data, the little data, and the “intangible” data 
  • Conclusion