What Is Clinical Documentation Improvement (CDI), and Why Is It Vital to Your Healthcare Data?

Whether you’ve heard the term or not, clinical documentation improvement has a long history within the healthcare industry. Its purpose is simple: verify that medical records are complete and accurate. Why have an acronym for something that seems so straightforward? Because evidence suggests that healthcare is in need of better data management. Here’s why it’s important that you make CDI a priority, and how to go about obtaining trained CDI specialists for your organization.

Data Accuracy Means Greater Reimbursements

According to AAPC, clinical documentation improvement programs became well known back “around 2007 when the Centers for Medicare & Medicaid Services (CMS) implemented Medicare Severity Diagnosis Related Groups (MS-DRGs).” This led to an increase in reimbursements and a lower risk for noncompliance, both obvious benefits to any healthcare organization.

So where did CDI initially run into trouble? It put more reliance on in-house providers and their nursing staff to perform this document review. If you’re already aware how much time doctors spend on paperwork, it shouldn’t come as a surprise that these new requirements meant added pressure on an increasingly overwhelmed system. Many healthcare entities opted for medical scribes to offset this burden; some were successful, while others struggled due to high costs and turnover.

That’s why CDI specialist training has become so important. Those applicants who qualify and complete training are recognized by AHIMA for the standards and skills necessary to understand, interpret, and organize medical data.  As AAPC notes, CDI specialists often have “both clinical and medical coding backgrounds” which allow them to “[bridge] the gap” between both, all while ensuring accurate documentation. As AHIMA notes, that coded data can then be “translated into quality reporting, physician report cards, reimbursement, public health data, disease tracking and trending, and medical research.”

Clinical Documentation Improvement Leads to Better Health Outcomes

The less time physicians spend focusing on paperwork, the more they can spend on their patients. As EHRIntelligence highlights, one doctor’s CDI allowed her to see twice her normal patient volume, and more time to compare observations with nurses’ aides and assistants about “any subtle changes” they had noticed in those patients. The doctor in this particular example used an EHR tool to optimize her workflow, but there are a diverse range of CDI-based solutions available. Some are performed through automation, while others rely on the knowledge and skillsets of trained professionals. This blending of medical skill and technology is important, as EHRIntelligence notes that the future of clinical documentation improvement may soon rely on ambient intelligence derived from sensors, processors, and machine learning.

Keep in mind that trained CDI specialists can also offer long-term benefits to the health outcomes of patients beyond your own practice. Your data can be used to inform public health policy, direct the appropriate funding for research and development, and even influence evidence-based resources (EBRs) that will continue to inform and assist medical professionals across the industry.

Apply Your Own CDI Program

Do you have your own CDI program already in place, or are you looking for ways to add one? Would you prefer keeping this program in-house, or would you consider outsourcing it? These answers will help you decide whether it’s time to partner with HCRS for your clinical documentation improvement. Our specialists have been trained to meet all requirements set by AHIMA in order to ensure the accuracy and integrity of your medical data. 

This data management can also include concurrent reviews, coding, and auditing as needed to improve your reporting, increase your reimbursements, and benefit the health of your patients for years to come. 

Worried about cost? Consider that our auditing services alone identify an average of eight dollars in incorrect payments for every one dollar invested in our services. You’ll see similar cost savings when it comes to CDI and other areas of data management. And when it comes to experience, we’ve got plenty of government and private sector success stories we can share.

When you’re ready, let’s schedule some time to talk about the CDI specialist training needs of your organization.