Clinical Documentation Improvement (CDI) when implemented successfully bridges the gap between clinical documentation and coded data. It results in higher reimbursement and better patient care. The downside? It is complex, time-consuming and increases the time clinicians spend on administrative tasks.

Every patient visit generates multiple data points, it is imperative to collect and document this information to meet reimbursement and compliance requirements. EHRs have modernized the documentation process and it now takes a few clicks to input and document information. But clinical documentation still remains a herculean task for healthcare providers.

Most healthcare organizations struggle to kick start CDI initiatives. This article aims to explain what clinical documentation is, the benefits of it, and how it helps providers meet the double bottom line of great patient care and improved reimbursement.

What Is Clinical Documentation Improvement?

Clinical Documentation Improvement is a set of measures taken to ensure the correctness and completeness of patient records. It is a process designed by hospitals to drive up the accuracy of the documentation process. CDI programs reduce denials and bring underlying documentation issues to the surface.

Impact and benefits of a CDI program

From a clinical perspective, the major benefit of CDI is updated and accurate patient data. By incorporating workflow management tools and hiring a CDI specialist physicians can minimize the time spent on administrative tasks and spend more time with patients. Poor documentation impacts patient care and increases re-admissions. It affects the quality and continuity of care. Accurate patient records help providers to communicate with patients regarding treatment plans and next steps more efficiently.

Maximize revenue through CDI

A high-performing revenue cycle rests on clear, reliable patient data. It is the most important piece of the RCM puzzle. Payers turn to clinical documentation and medical coding to reimburse claims. Incorrect codes or unclear documentation will lead to penalties and denials. Enhanced data collection results in higher reimbursement.

According to a survey by Black Book Market Research, nearly 90% of hospitals that implemented CDI collected 1.5 million more in revenue and claims reimbursement.

The additional revenue could be tied to more accurate case mix index that were generated through CDI programs. A CDI solution clearly indicates the severity level of the cases handled by an organization. A higher case mix index proves that the hospital treats complicated cases and hence must receive higher reimbursement for its efforts

After implementing a Clinical Documentation Improvement plan an Arizona based medical center increased reimbursement by 20%. Additional diagnosis capture and a higher case mix index resulted in $558,000 in a few months. This can be the power of implementing a CDI solution.

Does better documentation lead to physician burnout?

The answer is unfortunately, a yes. Clinicians cite administrative duties as a major concern. Research has proven that there is a strong link between physician burn out and increased administrative responsibilities.

A survey by Athena Health reveals that excessive documentation is a leading cause of physician burn out. 91% of respondents felt that the burden of regulatory requirements is worsening. To help meet documentation and regulatory pressures it is mission-critical to adopt workflow management tools or hire CDI specialists to close the loop between clinical care and the revenue cycle.

Close the loop with our CDI specialists

SolvEdge brings to the table 20+ years of experience and several successful engagements with leading hospitals. Our coding integrity team and CDI specialists can help you get started and attain CDI success.

• We can implement a training program that improves coding accuracy and competency.
• Create a road map that ensures consistent adherence.
• Help your hospital optimize CDI initiatives

If you are looking to free up front office staff and bolster POS revenue CLAfly can help you. It is an intuitive patient-centered solution that your patients would love to use See why.