Improving Coding Accuracy via Clinical Documentation Inprovement Education
The documentation of diagnoses by physicians and advanced practice providers is important for communication, billing, and quality metrics. Despite this importance, many providers lack training for and comfort with proper documentation. The performance of the children’s hospital was analyzed and compared to 85 other hospitals by assessing the expected length of stay and risk of mortality for two conditions: acute respiratory failure and sepsis. Before any interventions, the hospital was statistically superior to the cohort average in two of four categories, but inferior to the top performers in the cohort in three of four categories. To improve the performance didactic lectures to three pediatric inpatient divisions and the pediatric residency were provided. After the interventions there was an increase in the desired outcomes of expected length of stay and risk of mortality for both conditions, though this did not reach statistical significance. The hospital continued to be statistically superior to the cohort average, and now was no longer statistically below the top performers for three out of four categories. This shows an improvement through the interventions, and the use of these metrics is a valid way to follow documentation effectiveness.
DeMartini, MD, Theodore, "Improving Coding Accuracy via Clinical Documentation Inprovement Education" (2022). Master of Science in Operational Excellence (OpX) Capstone Presentations. Paper 4.