Clinical Documentation Integrity – Success in Written Policies and Procedures

Clinical Documentation Integrity Success in Written Policies and Procedures-1

While writing policies and procedures often seem to be time-consuming and a challenge, they have many positive benefits that cannot be overlooked. For Clinical Documentation Integrity (CDI) program having written policies and procedure is part of compliance and the day-to-day operations of the CDI staff.

When we think about written policies and procedures (P&Ps) we often get or receive a groan or even a snarl from the individual you are talking to. The perception of developing P&Ps is often uncomfortable and often seen as a chore. However, having written policies and procedures is one of the basics for any employment task, job, and/or function. In addition, the Office of Inspector General (OIG) has stated several times in their Compliance Guidance that organizations must have policies and procedures in place.

Successful clinical documentation integrity (CDI) programs facilitate the accurate representation of a patient’s clinical status that translates into coded data. The translation of coded data is performed by coding professionals into quality reporting, physician report cards, reimbursement, public health data, disease tracking and trending, and medical research. This is a true example of the teamwork and collaboration of CDI and Coding staff. The foundation of this is having consistent policies and procedures in place, not hearsay but formally written P&Ps.

The “policy” is the portion that provides specific guidance, provides rationale or reason for the policy and the scope of the policy. The “procedure” portion will outline the detailed function(s) and the steps to perform the function(s), the action to be taken and tasks to complete or avoid. The written P&Ps help to provide expectations of the job and duties for all employee’s or an individual department of employee’s.

In addition to having a written Mission Statement, Goals and Objectives for CDI, there are some industry standard policies and procedures that we see, several of which both the American Health Information Association (AHIMA) and Association for Clinical Documentation Integrity Specialists (ACDIS) have published. The following is a short list of “some” of these policies and procedures:

  • CDI Concurrent Query P&P
  • CDI Concurrent Review Productivity P&P
  • CDI Query Escalation P&P
  • CDI Query Retention P&P
  • CDI Staff Telecommuting P&P (usually HR also has a P&P for this, when PHI is concerned, special provision and security needs to be in place.)
  • CDI Physician Education
  • CDI Ethics and Compliance (use the AHIMA and/or ACDIS Code of Ethics as a basis)
  • CDI Quality Review (Auditing and Monitoring) – this will help to ensure the CDI team follows the query policy and that queries do not incorrectly or unduly influence medical record documentation.

There certainly are other P&Ps that could and should be developed, and this may depend upon which electronic health record (EHR) system you have and/or the type of CDI software you have as some of these vendor supported systems have specific requirements for data collection.

Think about your own CDI program and ask the question, “Do we have written policies and procedures for all the important and key functions and tasks?”  This answer may be yes, a partial yes or a no. The best practice is to have written P&Ps that you review and update every one or two years. When the specific function or task changes, the P&P should be reviewed and updated accordingly. Having P&Ps builds upon a culture of transparency, efficiency and compliance. The results of having P&Ps in place can help to bring about a successful CDI program!


References: The Benefits of Creating Effective Policies & Procedures – CFO Edge; AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice, Practice Brief, 2019.


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AHIMA Approved

This program has been approved for continuing education unit(s) (CEUs) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting of Approved CEUs from AHIMA does not constitute endorsement of the program content or its program provider.