How do you document and code for clinical decision support (CDS) interventions?

1 Step 1: Identify the CDS intervention

The first step is to identify what type of CDS intervention you are using or receiving. There are different categories of CDS interventions, such as computerized reminders, order sets, clinical pathways, diagnostic support, and reference information. Each category has its own purpose, scope, and format. You should document the name, source, and description of the CDS intervention, as well as the date and time of its use or delivery.

2 Step 2: Document the patient's data and context

The second step is to document the patient's data and context that triggered or influenced the CDS intervention. This includes the patient's demographics, vital signs, diagnoses, medications, allergies, lab results, and other relevant information. You should also document the patient's goals, preferences, and values, as well as any social, behavioral, or environmental factors that affect their health. This will help you justify the appropriateness and necessity of the CDS intervention.

3 Step 3: Document the CDS recommendation and rationale

The third step is to document the CDS recommendation and rationale that the CDS intervention provided or suggested. This includes the clinical question, the evidence-based answer, the level of confidence, and the source of the evidence. You should also document the benefits, risks, and alternatives of the CDS recommendation, as well as any caveats, limitations, or exceptions. This will help you evaluate the quality and reliability of the CDS intervention.

4 Step 4: Document the clinician's response and action

The fourth step is to document the clinician's response and action to the CDS intervention. This includes the acceptance, rejection, modification, or postponement of the CDS recommendation, as well as the reason and explanation for the decision. You should also document the outcome, impact, and feedback of the CDS intervention on the patient's care and health status. This will help you measure the effectiveness and value of the CDS intervention.

5 Step 5: Code for the CDS intervention and related services

The fifth step is to code for the CDS intervention and related services that you performed or received. This includes the codes for the CDS intervention itself, such as the category, type, mode, and frequency of the CDS intervention. It also includes the codes for the services that were influenced or supported by the CDS intervention, such as the evaluation and management, diagnostic testing, medication management, and care coordination. You should use the appropriate coding systems, such as ICD-10-CM, CPT, HCPCS, and SNOMED-CT, and follow the coding guidelines and rules.

6 Step 6: Audit and improve the CDS intervention

The sixth step is to audit and improve the CDS intervention based on the data and feedback that you collected and documented. This includes the analysis of the CDS intervention's performance, accuracy, compliance, usability, and satisfaction. It also includes the identification of the CDS intervention's strengths, weaknesses, opportunities, and threats. You should use the audit results to update, modify, or discontinue the CDS intervention, as well as to share best practices and lessons learned.

7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?