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Overview: Diabetes Mellitus Documentation

CDI and Quality depts. routinely track coding results that affect their business lines.  This data has indicated a need for understanding the implications of coding on many metrics that both hospitals and clinics follow to include, but not limited to: accuracy of primary dxs, LOS, DRGs, Readmission, Mortality, PSIs, HACs, and POA indicators.  The need for continued conversations regarding these various metrics, indicates the need for more formalized resources available to educate providers.

Providers are documenting an unspecified diabetic patient when they are actually treating and managing a diabetic patient with hyperglycemia and several diabetic complications.  Therefore, there is not an accurate reflection of the severity of illness of their patients and the higher level of care needed to treat and manage the patient’s diabetic conditions.  A separate issue was also that diabetes was incorrectly being added to the diabetic registry due to provider documentation

This module is designed to help providers understand the Clinical Documentation Improvement (CDI) Program. Through examples and interactive exercises, the learner will be exposed to the key components of CDI as well as various Quality metrics.