How Clinical Documentation Improvement Benefits Healthcare Organizations

Featured article by Catherine Malli-Dawson

State of CDI

Recently, there has been a significant increase in Clinical Documentation Improvement (CDI) requests from health systems. This is mostly due to a push to improve revenues after the impact of the COVID-19 pandemic. Additionally, healthcare organizations recognize that patient care benefits when there is an active team of CDI specialists supporting a facility. Good CDI ensures more efficient and timely communication between the physician and the back-office team. CDI improves the quality of documentation, speeds up coding, improves the accuracy of claims, and reduces denials.

The role of CDI has been growing in importance on the IP and facility side of health systems. Now, there is a growing interest in the OP setting driven by changes to reimbursement. Facilities are now more open to remote support for CDI roles.

Certifications and Credentials

To ensure your team has the right experience to support good CDI, consider the following certifications and credentials:

• Certified Clinical Documentation Specialist (CCDS): Individuals with this credential have an understanding of anatomy, physiology, pathophysiology, and pharmacology, medical coding guidelines, CMS, and private payer regulations related to the Inpatient Prospective Payment System. They will also have an ability to analyze and interpret medical record documentation and formulate appropriate physician queries, along with an ability to benchmark and analyze clinical documentation program performance.
• Certified Clinical Documentation Specialist - Outpatient (CCDS-O): Those with this competency will have a baseline for CDI in the outpatient setting. This includes physician practices, hospital clinics, and the emergency department.
• The ACDIS-Approved CDI Apprentice Program: This certificate is comprised of foundational CDI experienced with a review of core compliance and ethical principles. Candidates will receive a certificate of CDI foundational training and can designate themselves as an ACDIS-Approved CDI Apprentice.

What Does a CDI Professional Do?

The main role of the CDI professional is to help providers achieve complete and accurate documentation. Responsibilities also include facilitating and obtaining appropriate provider documentation within the medical record for clinical conditions and treatments required for an accurate representation of the severity of illness, expected risk of mortality, and complexity of care of the patient. In addition, they should exhibit a thorough knowledge of clinical documentation requirements as they relate to the classification systems, MS-DRG assignment, and the clinical conditions and treatment needs of the patient population. CDI professionals should educate members of the patient care team and others regarding documentation guidelines. They also facilitate the overall quality and completeness of the clinical documentation to accurately represent the severity, acuity, and risk of mortality profile of the patient being treated. Many facilities have CDI software integrated into their EHR systems, so CDI professionals should have familiarity with:

• Iodine
• ChartWise
• Nuance
• Optum
• 3M 360

Benefits

Once your team is ready to support CDI, your organization will experience improved operational workflows, enhanced quality of patient care, reduction in errors and higher quality, improvement in denials management, and better communication. All of this will result in better patient care, revenue capture, physician satisfaction, and more efficient workflows. Additionally, there can be great financial benefits from CDI. Nearly 90 percent of hospitals with more than 150 beds and outsourced clinical documentation functions saw gains of at least $1.5 million in appropriate healthcare revenue and claims reimbursement following CDI implementation, a 2016 report from Black Book Market Research found. To ensure your organization reaps these benefits, ensure that you have a robust CDI system in place, and the talent on your team to support it.