Case study: When CDI is under the revenue integrity umbrella

Clinical documentation improvement (CDI) is shifting gears to clinical documentation integrity at WakeMed Hospital in Raleigh, North Carolina. The CDI department recently transitioned from being under the health information management umbrella to falling under revenue integrity.

“Integrity reflects more of what a CDI program is about when you think of what the ultimate goal is: achieving an honest and complete representation of a patient’s stay in the hospital,” says Shameka Hooks, MHA, RHIA, CDIP, CCS, AHIMA approved ICD-10-CM/PCS trainer and manager for clinical documentation integrity and coding at WakeMed Hospital.

In her day-to-day operations, Hooks focuses on fostering educational opportunities for staff growth and ensuring staff resources.

“The revenue integrity field sort of fell into my lap due to the recent transition of clinical documentation improvement to the revenue integrity field,” she says.

Hooks’ team’s workday revolves around reviewing clinical documentation in patients’ medical records to ensure it accurately reflects the care given. To be successful, she relies on her relationships with colleagues. 

“I find that good physician relationships are imperative in reaching your goals—whether it’s for education on a particular clinical topic, how procedures are performed, or just answering one of the CDI specialist queries,” Hooks says.

Hooks is currently working on extending WakeMed’s CDI program into the outpatient area. The initial goal is educating outpatient-focused CDI staff on risk adjustment and the principals of coding in the outpatient arena, says Hooks. The challenge is simultaneously obtaining data on outpatient encounters to identify the areas to start outpatient CDI for improvement.   

As Hooks reflects on her time spent in revenue integrity, she has the following advice for others in the field:

• Surround yourself with positive people. Find a mentor you can trust for advice and career growth. 
• Build a trusting relationship with your staff. Schedule time to get to know your colleagues, and make time for them to get to know you. By doing this, you let them know that you respect and value them professionally and personally. Building trust will allow you to develop open and honest communication. 
• Grow and adapt with the ever-changing healthcare field. Adapt to changes or you will be left behind while everyone else is moving forward. Seek out educational opportunities to grow your skills. Attend conferences and webinars in the healthcare field.

“I try to stay ahead of changes in the healthcare field by signing up for educational classes that are offered through the various associations our field is associated with such as American Health Information Management Association, the Association of Clinical Documentation Improvement Specialists, and their state affiliates,” says Hooks.

With all the nuances of clinical documentation integrity, patient care is what keeps Hooks interested in the healthcare field.

“My favorite part about working in this field is knowing that what I do impacts the patient’s care on so many levels,” she says. “For instance, what we do as CDI reflects how an account is coded and the coded information is used for reimbursement, trending and tracking data, quality outcomes, and physician report cards.”