Based on the current situation, there is a need for change in escalating documentation and coding process. The following policies will not only help maintain the hospital documentation validity but also ensure that the information is useful for internal use. The proposal comes in light of the pending query loads with the physician. The proposal is guided by AHIMA/ACDIS provision.
According to AHIMA, all cases regarding clinical validity and practitioner documentation should first be referred to the to the CDI manager. The CDI should establish the inconsistencies and escalate the issue to the relevant authority based on the source of the validity situation, such to HIM when the case involves the physicians. HIM, for example, will consult the relevant authority and provide a comprehensive feedback to the CDI. Some of the AHIMA guidelines which are key in the current stalemate include: (CDI, 2013).
- The administrative representative should the CDI manager of the concurrence
- The a...