One major way organizations can reduce claims denials is to truly focus upon root cause analysis, take a hard look at avoidable unnecessary denials, develop a management action plan and engage in process improvement that holds stakeholders accountable.Case in point, bring into the fold CDI specialists and hospitalists who in some respects to medical necessity & clinical validation denials as well as DRG downcodes.

Today’s model of CDI predicated upon retrospective reactive repetitive queries fails to achieve scale and sustainable improvement for a variety of reasons. The biggest obstacle to achieving true documentation improvement over time as individual hospital programs mature is the current system is not designed or intended to positively affect any patterns of documentation beyond diagnoses typically appearing in the chart 24 to 48 hours after admission to the hospital.

Clinical Documentation Integrity, previously referred to as Clinical Documentation Improvement, has been a strong passion of mine for the past twenty-seven years, predating the recognition of CDI as a profession. I am always advocating for and will continue to advocate for a radical transformational change in current CDI processes that do not lend themselves to true physician engagement as willing active participants. Active physician engagement beyond

Listen to Glenn cover various points in the CDI arena. You can check out the website this podcast is featured on here.

Most Clinical Documentation Integrity (CDI) programs are mislabeled and misidentified in the present format. Integrity is defined as the quality or state of being complete or undivided per Merriam-Webster. A few years back the association representing the Clinical Documentation Improvement Specialist’s community elected to replace the “Improvement” part of the name to “Integrity”, now referred to as Clinical Documentation Integrity Specialists.

CDI programs have strong potential to significantly raise compliance risks for the hospital or health system in which the program operates. Compliance departments strive to minimize and alleviate the numerous risks associated with the myriad of components associated with and fundamental to the delivery of healthcare. Clinical documentation improvement initiatives can work in tandem, align and collaborate with the compliance department’s goals and objectives,

Most Clinical Documentation Integrity (CDI) programs are mislabeled and misidentified in the present format. Integrity is defined as the quality or state of being complete or undivided per Merriam-Webster. A few years back the association representing the Clinical Documentation Improvement Specialist’s community elected to replace the “Improvement” part of the name to “Integrity”, now referred to as Clinical Documentation Integrity Specialists.

Most Clinical Documentation Integrity (CDI) programs are mislabeled and misidentified in the present format. Integrity is defined as the quality or state of being complete or undivided per Merriam-Webster. A few years back the association representing the Clinical Documentation Improvement Specialist’s community elected to replace the “Improvement” part of the name to “Integrity”, now referred to as Clinical Documentation Integrity Specialists.

A recent conversation with a CDI colleague of mine raised several interesting points I would like to share for consideration. We were discussing an initiative where the CDI specialists and their department were going to transition to working on the floor reviewing records with the intent of conversing more with the physicians and residents on documentation improvement opportunities. The impetus of the initiative to transition to the floor was to be more readily

The Ideal State of CDI- Collaborating Synergistically With All Other Ancillary Healthcare Roles to Achieve Real Meaningful Improvement in the Communication of Patient Care. Let’s Not Forget the Patient in any CDI Initiative. Reimbursement is a byproduct measure of documentation improvement that is sustainable over time. Rather than CDI specialists focus primarily upon capture of diagnoses, i.e., CC/MCC, principal diagnosis shift, HAC and PSI clarification