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CDI Course Helps Physicians Reflect Quality of Care

The Health Information Department's Clinical Document Integrity (CDI) Program is offering deep-dive education to help keep physicians up-to-date on new documentation requirements that can impact how the quality of their work is represented.

The 90-minute CDI Physician Power Course and Refresher sessions cover how accurate and specific clinical documentation guides ICD-10 code assignments, as well as documentation's impact on quality outcomes, data integrity, value-based purchasing and research.

"As clinicians, we are well-versed in the medical care of our patients, but when it comes to the task of accurately capturing a patient’s clinical condition to conform with current documentation standards, it’s important to stay current with the latest rules and guidelines," said course attendee Nattapaun Thepyasuwan, DO, a hospitalist with Genesis Hospitalist Medical Group and a physician advocate at Cedars-Sinai.

As a physician advocate, Thepyasuwan works with CDI to help resolve queries around the specificity of submitted clinical documentation. She said many of the queries she assists with are common and easily resolved with better understanding of current documentation trends.

"For example, the term 'urosepsis' used to have a specific code several years ago. Based on changes to coding guidelines, per ICD-10, urosepsis no longer has a code. A provider must be queried for clarification if he or she documents this term," Thepyasuwan said. "Without attending this course and learning about these ongoing changes, I would not have known that. To stay up-to-date, I try to attend once a year."

The course also examines how the public reporting of healthcare provider statistics plays a significant role in the decisionmaking of insurance companies and the public when considering which healthcare providers and organizations are preferred or to be avoided.

The sessions, which can be tailored to departmental needs, underline how documentation practices affect severity of illness (SOI) and risk of mortality (ROM) scoring, in turn driving the expected length of stay (LOS) and the case mix index (CMI).

The course also provides access to CDI Program resources that can assist physicians with their documentation needs.

General sessions will be held on the following dates:

  • 10/02/18 3:30-5 p.m. Pavilion, PEC 5
  • 11/06/18 3:30-5 p.m. Pavilion, PEC 5
  • 12/04/18 3:30-5 p.m. Pavilion, PEC 5

Employees wishing to attend a general session or request a built-to-need presentation for their department can contact Health Information Department Supervisor Mark Dale Tajon at 310-423-3052 or MarkDale.Tajon@cshs.org.