It has been more than a year since ICD-10 was implemented, which has allowed for some degree of normalization for clinical documentation improvement (CDI) programs. Time and resources can now be redirected towards building, strengthening or expanding CDI programs to meet the increasing demands of documentation requirements. Below are three areas to consider when selecting a CDI vendor partner.

Experience

How many years of experience does the vendor have and in what types of settings? Implementing CDI programs at a community hospital versus an academic medical center or trauma center are starkly different. Community hospitals typically see less complex patients with more common conditions. Academic medical centers and trauma centers see the sickest patients and perform the most complex procedures. It is important to make sure the vendor has experience with the service lines offered at your hospital to ensure optimal CDI strategies are deployed. The vendor should be able to tailor their training and implementation approach based on your organization’s unique needs.

Roles

The most successful CDI programs consist of strong physician leadership, clinically strong clinical documentation specialists and vastly experienced coding experts. Each group plays a key role in ensuring success. Ensuring collaboration between each group is integral to the long-term vitality and success of a program. Difficulties arise within CDI programs when there is an imbalance or deficiency in one of these groups. An ideal vendor will be able to provide expertise and guidance from a physician, clinical, and coding perspective. The vendor should be able to assess and identify where support is needed and then deploy a plan to improve areas of weakness.

Knowledge Base

CDI programs are always evolving. Whether it be a major change like the implementation of ICD-10 or smaller but significant changes released in Coding Clinic, it is critical that your vendor is up to date with the latest coding guidance (e.g., automatic linking of hypertensive heart and kidney disease) and clinical definitions (e.g., third definition of sepsis). It is important to ask your vendors if their materials are up to date and if they are prepared to lead discussions and provide guidance regarding controversial rule changes or clinical definitions.

Selecting a vendor can be a difficult process. It is important for your organization to identify priorities and develop specific questions for your potential vendors to see if they can address your needs. If you are starting a new program, you will want to seek a vendor with extensive experience with your facility type. If you have an established program and are looking to reinvigorate your program, look for a vendor that can provide a team approach to help identify areas for improvement, strengthen identified weaknesses, and provide support where needed most.