Q&A: Defining the benefits of chart reconciliation

Q: My team and I are responsible for clinical documentation improvement (CDI). We’re considering adding a reconciliation element to our CDI review process next year. In your experience, what’s been the biggest benefit of performing reconciliation on charts?

A: For me, it’s a toss-up between the education that CDI specialists gain and the reassurance that CDI’s hard work in reviewing and/or querying is reflected in the final codes. Our work product can be conveyed through various metrics (case-mix index, complication and comorbidity/major complication and comorbidity capture rate, query response, query impact including financial, etc.) as well as external hospital/system rankings from CMS and other groups (Vizient, U.S. News and World Report, etc.). We all want to ensure that our organizations are reflected appropriately in those measures, and reconciliation helps support this goal. As with CDI’s normal query process, some accounts that are reconciled could wind up with a lower Diagnosis-Related Group or lower severity of illness/risk of mortality. But across all our work, we aim to ensure that the documentation truly reflects the care being provided to our patients.

Editor’s note: This answer was excerpted from a NAHRI Journal article written by Lena Wilson, MHI, RHIA, CCS, CCDS. Download the October 2022 issue of the NAHRI Journal here. Find more NAHRI resources on CDI here.