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.