Clinical Documentation Improvement

Clinical Documentation Improvements Program by CBS

Along with our other services, Coding & Billing Solutions is fast becoming a leader in Clinical Documentation Improvement. CBS is working with clients to help them capture appropriate revenue that would have otherwise been missed; we work in tandem with the coding team to illustrate patients severity of illness and risk of mortality.Health systems invest a lot of resources into the care of their patients. We help educate providers to accurately document diagnoses their treating. Now, we would like to help your organization benefit from our expertise in this critical area.

What Is Clinical Documentation Improvement?

Clinical documentation improvement (CDI) is the process of studying the clinical documentation in a patient’s medical records for completeness and accuracy. Proper CDI by a skilled organization like Coding & Billing Solutions involves a review of a patient’s diagnosis, diagnostic findings, and disease process to reveal what could be missing, under-coded or incorrectly coded. Our CDI specialists have both clinical and medical coding backgrounds and have deep expertise in identifying these gaps.

Although specialist consults, lab tests and diagnostic tests can also be housed in a patient’s medical record, clinical documentation, as it relates to Clinical Documentation Improvement, generally refers to the entries made by a medical provider or clinical staff member who is responsible for the patient’s care during in-patient visits. While the implementation of electronic health record (EHR) systems has streamlined many aspects of patient care and claim submissions, medical providers still have responsibility for maintaining the entry of clinical information concerning the care that they have provided to their patients.

To help providers succeed in this task, Coding & Billing Solutions’ CDI specialists are responsible for reviewing patient medical records to ensure that the documentation reflects the specific current conditions of a patient to allow for accurate coding of their health status.

The Benefits of Clinical Documentation Improvement in Inpatient Settings

For Inpatient settings, CDI support from Coding & Billing Solutions’ Team can improve the accuracy of coding and billing. This has two benefits. The first is an improvement in the initial payment of claims. The second is protection from audits on improper claim submissions resulting from poor documentation. An unfavorable audit can result in the payment of a fine and/or the return money erroneously collected from payers. As a result, the role of Clinical Documentation Improvement in claims processing in healthcare facilities includes both increasing the accuracy of initial reimbursement and preventing expensive consequences from reviews by authorities.

CDI’s Role In Revenue Maximization

Ensuring that reporting occurs for all conditions that are clinically supported is extremely important due to the way that inpatient facility reimbursement works. To understand how a Clinical Documentation Improvement program will provide financial enhancement for an inpatient facility, it is important to understand Medicare’s DRG payment system, which is also adapted for use by many non-Medicare payers as well. DRGs (Diagnosis Related Groups) are groupings of a patient’s diagnoses that are related and effect care during inpatient stays. The principal diagnosis for a patient, as well as up to 24 secondary diagnoses, including comorbid conditions (CC) or major comorbid conditions (MCC), drive the DRG assignment.

CDI’s Role in Improving Patient Care

Implementing a Clinical Documentation Improvement program also produces significant benefits in terms of patient well-being. Low quality records can impact patient care in a healthcare facility by affecting continuity and quality of care. The review of documentation by our CDI specialists creates improved communication between all the providers involved in the patient’s care and can improve patient care and reduce the length of stay for the patient. Furthermore, a Clinical Documentation Improvement program can help reduce avoidable readmissions by enhancing care coordination and communication between caregivers and their patients at the time of discharge. Payers recognize the benefits that these programs generate and reward facilities that reduce readmissions. One such example is the Hospital Readmissions Reduction Program (HRRP), which is a value- based purchasing program that reduces payment to hospitals that experience excess readmissions.

CDI in the Outpatient Setting

In the outpatient setting, a CDI program can be just as impactful in terms of financial and clinical outcomes as it is in the inpatient setting. A well-functioning revenue cycle is essential for outpatient providers and claim denials due to incorrect coding can disrupt the timely payment of services. The primary objective of a CDI program for physicians in an outpatient environment is to prevent such denials and amendments while ensuring complete clinical documentation. For instance, with the change in CPT® 2023 E/M guidelines for office and outpatient visits, accurate and specific clinical documentation is crucial to demonstrate medical necessity for the CPT® codes submitted on a claim. Our CDI specialists can help providers and coders prepare for coding and coverage changes that affect documentation requirements. The CDI specialist can continue to assist by reviewing documentation and claims to validate the diagnosis codes accurately reflect what the provider recorded and support medical necessity for the level of E/M code reported on the claim. Apart from the documentation for services such as office visits, immunizations, and minor procedures, CDI’s role extends to patient outcome-based quality services. If a physician or physician group is eligible to participate in the MIPS, positive or negative payment adjustments could be realized based on reporting of high-value, patient-centered care.

Clinical Documentation Improvement & The Inpatient Process

The CDI program in a hospital follows a concurrent process where a specialist reviews the patient’s documentation during their inpatient stay and queries the provider for updates before discharge. If the documentation contains nonspecific terms, uncertain diagnoses, unaddressed diagnostic test results, or diagnoses not reiterated by the attending physician, the CDI specialist can immediately request clarification from the provider. Our CDI specialists are deeply familiar with the industry standards for ethical and appropriate queries that are not suggestive of new information but focus on clarifying the available facts in the medical record. For instance, multiple-choice queries should include options like “clinically undetermined” or “not clinically significant.”

Clinical Documentation Improvement & The Outpatient Process of CDI

In an outpatient setting, the CDI program operates retrospectively, with the CDI specialist reviewing medical record documentation after the patient has left the office visit. Depending on the CDI team’s workflow, this review can occur weeks or even months after the date of service. Unlike inpatient facilities, communication to the provider is focused on documentation improvement education rather than queries. During the review, the CDI specialist identifies issues such as missing medication conditions, undocumented cause-and-effect relationships between conditions, and under-reported diagnosis severity. Careful wording is crucial when communicating these retrospective review findings to providers. Although our CDI specialists cannot suggest a particular diagnosis, they can educate providers on the importance of using specific terms and including the status of all coexisting conditions that affect medical decision making. Furthermore, the CDI specialist can inform providers on how this documentation affects coding. Another critical aspect of outpatient CDI is identifying social determinants of health (SDOH) to improve patient health outcomes. SDOH are non-medical factors that influence health outcomes, and in the wake of the COVID-19 pandemic, their importance has become increasingly evident. CDI specialists can assist in identifying SDOH using assessment tools such as PRAPARE® from the National Association of Community Health Centers (NACHC). By coordinating efforts with the office staff, CDI specialists can ensure that patients receive social services ordered by physicians beyond medical attention for diseases.

Implementing a Clinical Documentation Improvement Program With CBS

There are several compelling reasons to implement a CDI program with Coding & Billing Solutions, including the submission of accurate claims, favorable audit results, a healthy revenue cycle, and improved health outcomes for patients. However, implementing a CDI program can be challenging if all parties involved, including physicians, administrators, CDI specialists, and coding and billing staff, do not fully understand the program’s purpose and process and how each role contributes to its success. It is crucial that all stakeholders understand their vital role in the CDI program’s implementation and actively work together to ensure its success. If you would like to explore how implementing a CDI program with Coding & Billing Solutions,
contact our Founder & CEO Sheri Hovan today.