Why Clinical Documentation Improvement Is Necessary

Regardless of the deadline that the Centers for Medicare and Medicaid (CMS) have decided on for the ICD-10 implementation, clinical documentation improvement is becoming a necessity for hospitals.

CDI, as it is typically used in hospitals, utilizes consultants who assess clinical documents and provide responses to physicians, says Dr. Robert Gold, CEO of DCBA. The responses given are intended to provide solutions to issues with documentation including questions about the coding used, quality, and management of the overall care of patients. As Dr. Gold Says, “Paint the picture of the patient properly with words, so the coder can paint the same picture with codes.”

Healthcare organizations can realize positive changes in accuracy and compliance. Take a look at what this CDI Liaison Nurse had to say about working with DCBA’s team:

I am still amazed everyday at the intensity and level of cooperation with documentation from the majority of our physicians. And I don’t take credit for it. It is an expectation of the leadership here, the staff follow through willingly, and the rest just happens. The physicians are pretty accessible on the floors so we are able to make frequent contact with them and educate as needed. We even had a metabolic doc come up to us and ask how to document an unusual condition that was present on admission. Even the pediatric surgeons answer our queries. And we are presenting to the new docs coming on board at the end of the month. So life here is good.

CDI specialists can analyze queries and work with physicians on training. ICD-10 has become a motivating factor for many organizations to seek the assistance of CDI specialists. Proper documentation directly affects coding- the core of revenue and reimbursement. Accurate documentation is also essential for quality measure compliance as quality provides a foundation for care management and correct protocol procedures.

With so much to gain, many organizations have begun preparations for CDI with ICD-10 on the horizon.