UPMC Western Maryland Health System

“We immediately improved our processes. Staff welcomed the guidance and found the exercise confirming and reassuring. It boosted their confidence and morale.”

- Maria Moore, BSN, RN, CCDS, CCS, manager of CDI improvement, quality, and patient safety, UPMC Western Maryland Health System

CHALLENGE

Do you find yourself questioning the efficiency and compliance of your clinical documentation integrity (CDI) query process? Are you sure you’re adhering to industry best practices?

Maria Moore, BSN, RN, CCDS, CCS, manager of CDI improvement, quality, and patient safety at UPMC Western Maryland Health System, acknowledges the challenges in writing CDI queries. “Writing queries is difficult. It takes a great deal of time and effort and there are many potential pitfalls,” she said.

“The query has to be necessary, it must be compliant, it has to be clear, it has to be complete and yet concise. We don’t want to waste anyone’s valuable time,” she asserted.

The importance of CDI queries cannot be understated, however. Clear and precise clinical documentation captures the true nature of the patient’s condition and care provided. It is at the core of every patient’s care experience—directing decisions made and care provided by the clinical team and ensuring accurate reimbursement and quality scores.

SOLUTION

To confirm compliant standards and validate the CDI team’s query practices, UPMC Western Maryland retained AHIMA expertise

The AHIMA CDI Query Compliance Assessment evaluates healthcare query processes to ensure compliance and maximum effectiveness. Template agnostic, the AHIMA query assessment is effective, regardless of the type of query template used.

Steps in the AHIMA CDI Query Assessment Program:

• Provider selects 50 queries for AHIMA review—typically queries by a cross-section of staff reflecting a variety of patient conditions
• An AHIMA subject-matter expert (SME) who holds the AHIMA Certified Documentation Integrity Practitioner (CDIP®) credential reviews each query
• An AHIMA Compliant Query Rubric is created for every query, which includes comments and suggestions
• A second, credentialed SME peer reviews those findings and finalizes each rubric
• AHIMA meets with the organization to share findings and discuss recommendations

Common concerns identified using the assessment:

• Using the wrong query template
• Including information not relevant to answer the query
• Including non-clinically relevant answer options in the query
• Not including date and time of care provided or a patient observation
• Finding that a query wasn’t necessary (information needed was there all along)

OUTCOME

At UPMC Western Maryland, AHIMA identified several specific opportunities for improvement and provided clear guidance to address those areas. “We immediately improved our processes,” said Moore, describing how her organization has translated assessment findings into action. We use this information purely to educate the team and we stress that this isn’t punitive. Staff welcomed the guidance and found the exercise confirming and reassuring. It boosted their confidence and morale,” she added. 

Are you grappling with the complexities of CDI queries?

The UPMC Western Maryland Health System case study demonstrates the transformative impact of the AHIMA CDI Query Compliance Assessment. Elevate your CDI query performance and uncover opportunities for enhancement in your query processes. Contact us to learn how our solutions for healthcare providers will improve your CDI today.