Aaron DeBoerDuring a physician’s medical training, including residency and an internship, very little time is spent on how to accurately document and code services provided to patients. Even as a physician begins private practice or an employment arrangement, little time is reserved for instruction on coding and documentation accuracy. It should come as no surprise then that most physicians have a minimal appreciation of the tenets and impacts of correctly coding and documenting their work. 

Sue Egan

Physicians can benefit immensely from coding and documentation education. In fact, few other administrative functions performed by a physician will be as common and impactful. Many healthcare organizations have realized the value of this education and training opportunity and are actively pursuing clinical coding and documentation improvement (CDI) programs. Making these efforts successful takes careful planning and skillful execution by coding and documentation professionals.

Keys to Successful CDI Efforts

There are ways an organization can ensure positive results from a CDI program. Here are five key actions organizations can take to ensure success.

Do your homework:

  • Know which coding guidelines your organization uses, and understand the impact of the decision to use those guidelines. 
  • Identify who actually performs the coding and documenting to make it easier to target and resolve deficient practices.
  • Understand how each physician, within his specialty, compares to national and internal practice group benchmarks for coding and documentation accuracy. Making a comparison sets a baseline for potential improvement.

Arm your physicians with data, measure often, and provide feedback regularly:

  • Provide physicians with feedback on their evaluation and management distributions (e.g., biweekly or monthly, and annually). This feedback should include different distribution intervals (e.g., trailing 14 days, trailing two months, year-to-date totals). 
  • Compare these distributions with national, state, and internal benchmarks.

Target the physician’s unique learning needs:

  • Provide both individual and small group training because each offers a different environment for learning. Individual training and shadowing allows the educator to focus on individual needs, while small group training allows the educator to focus on common questions and dispel common coding and documentation myths.
  • Make the material relevant and interactive. Encourage the physician to ask questions and tailor the material to those questions. Ask to shadow the physician in his clinic following the education sessions.
  • Create an open line of communication between the physician and educator and ensure that all questions are addressed.

Engage physician leadership:

  • Identify a physician leader who can help to ensure that physicians view CDI efforts as an organizational priority.
  • Task the leader with ensuring physician compliance with government and commercial payer coding regulations.

Ensure the efforts are hardwired:

  • Work with your information technology team to ensure that the electronic medical record system facilitates good coding and documentation principles and helps the physician understand the appropriate code for the work performed.
  • Create a compliance plan and follow it. The compliance plan should ensure that all physicians receive regular audits and feedback on their coding and documentation. Physicians that do well should be audited no less than annually. Physicians that need improvement should be audited more frequently based on unique needs and educator resources.
  • Track progress and provide physicians with continued feedback.

The Benefits of Effective CDI

If executed poorly, CDI efforts can lead to physician dissatisfaction and frustration and/or only temporary improvement. If executed properly, however, CDI efforts will have significant and lasting benefits.

Aaron DeBoer is associate director, Navigant Healthcare, Denver.

Sue Egan is associate director, Navigant Healthcare, Suwanee, Ga.

Publication Date: Tuesday, April 23, 2013