Compliance Officer

The four pillars of compliance are training, policies and procedures, internal monitoring, and regular auditing. As presented in this book, initial and continuous training is an essential part of the clinical documentation program. Policies and procedures are also discussed and are important to the process. Internal monitoring should be performed by the clinical documentation manager. And finally, an annual audit of your program, whether internal or external, is important as well. As long as you are practicing all of these activities along with the standardized implementation (based on the seven criteria for high quality clinical documentation), you have an excellent insurance policy in place.

If you have trained your physicians and staff members appropriately and implemented the program in accordance with the training guidelines presented in this book, the clinical documentation professional (CDP) interaction with physicians should not be a compliance risk. In fact, your clinical documentation program should be an important part of your overall compliance strategy. There has been some concern that certain CDP practices such as leading queries or inquiries written on sticky notes or the physician’s interpretation of the question being asked of her may present a compliance risk.  If you have trained your physicians and staff members appropriately and implemented the program in accordance with the training guidelines presented in A Compelling Case for Clinical Documentation, the CDP interaction with physicians should not be a compliance risk.

The inquiry process is the key component of a clinical documentation program, and it is managed and created by the individuals responsible for implementing and maintaining the program. Therefore, the procedures for asking physicians to clarify their documentation should be designed to meet your organization’s specific needs. There are a few basic tenets that should drive the content of training for documentation reviewers. These are addressed in detail in the book and include:

• Use the criteria for high quality clinical documentation to generate queries.
• Ask questions in a non-leading manner.
• Record every question that is asked.