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Why Your Medical Practice Needs a Clinical Documentation Improvement (CDI) Program

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As most practitioners and nurses would agree, health records are the most critical document used within the medical care setting. After all, they are the primary vehicle for recording and communicating health information and ensuring continuity of care.

There are numerous pieces of information within a health record that are used for various purposes. For example, notes and information within these documents are used to evaluate adequacy and appropriateness of care. They also provide clinical data for research and show quality of care. On the financial side, these records can support reimbursement from insurance providers and make keeping the healthcare center profitable a reality.

In short, documenting the patient’s condition completely and accurately is a paramount part of the healthcare process. That is why it is so important to review your document program and have a plan for making needed changes for better accuracy.

What is a Clinical Documentation Improvement (CDI) Program?

So, what exactly is a clinical documentation improvement (CDI) program? Essentially, it is the process of improving healthcare records to ensure improved patient outcomes, data quality, and accurate reimbursement. The overall goal is to ensure the patient’s true severity of illness is documented and reported appropriately.

While that might all sound like a mouthful, what it all comes down to is having a process of reviewing your documentation to make sure your entire medical team is reporting healthcare data accurately and completely at all times. This is something that needs to be done often to ensure all protocols are followed and that your patients are getting the best care possible. It is also something that should be checked to discover any bad habits or problems that arise with specific staff member reporting.

Reasons for Clinics to Implement a CDI Program

Hospitals have been doing inpatient CDI programs for years and regularly make changes to their documentation protocols. The unfortunate part is that most individual clinics and doctor’s offices don’t have the same level of funding to be able to do this on a regular basis, nor does the staff usually have time in the day due to other responsibilities.

Think about this for a moment. What time during the day does an office manager or receptionist have to go through existing medical records and review them for complete and total accuracy? What about a medical biller or coder? Generally, their day is busy with just trying to keep up with the normal duties of their position. Thus, it can be a good idea to work with a third-party to implement a thorough CDI program.

Clinical Documentation and the Changing Healthcare Environment

The healthcare environment is rapidly changing, and it can be more critical than ever to ensure all patient health records are accurate and complete. In order to receive payment for health services rendered, the quality of records submitted can make a big difference in amount and speed of pay.

Payment systems utilizing ACOs and bundled payments incentivize efficient care, but also require physicians to document specifically, clearly, and accurately. In addition, the Physician Quality Reporting System (PQRS) also offers better benefits for having better health record documentation.

Plus, many health payers now use some version of value-based reimbursement that links financial reimbursement to patient severity of illness. This means that it is more vital than ever to capture and record accurate diagnoses.

What Can Individual Medical Practices Do?

When it comes to ensuring your individual medical practice has the most accurate health records possible, one option to consider is to hire a third-party to implement a CDI program. On a small scale, your organization can hire a medical coder with specific CDI experience to help review existing records and implement better protocols for new records.

Likewise, you can also opt to work with a third-party coding and billing partner, such as Symbion Coding (www.symbioncoding.com). We offer clinical documentation improvement advice and review within the services that we already offer, which can give your practices a two-fold approach to improved reimbursement and accuracy.

Both are excellent options that lead to one final and successful result: a better healthcare records system that ensures your patients are getting the best care possible and that your practice is receiving the appropriate reimbursement for the treatment provided.

Conclusion: Benefits of Having a CDI Program

What this all comes down to is that every medical practice should have a CDI program in some form. Whether this is an individual party who is trained to handle chart review tasks or a third-party organization with a wealth of experience analyzing records in bulk really comes down to your individual clinic needs.

However, the end result is still the same of better-quality documentation within the medical record. Better data and accurate reimbursement for the practice. And an overall reduced compliance risk associated with improper billing. For most practices, these benefits alone far outweigh the cost of hiring third-party help and make the CDI process incredibly worthwhile.


Jean Delva
Founder & CEO of Symbion Coding, Inc.
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