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.

I recently talked with a colleague on the phone who has been out of work for over a year now, this despite the fact the economy is performing well on all major indices. Now, granted my colleague has her age going against her as a strong headwind, she has been actively searching for a book-keeping related position day in and day out with little results. My colleague has been a bookkeeper for over twenty-five years with a very stable work history, having been at her last

I am thrilled to welcome Dr. Maria Mirt to the latest episode of the No Fears CDI Podcast! Maria joins us at the fascinating crossroads of primary care, operations, and clinical documentation integrity (CDI). Her insights are both practical and inspiring, especially for clinicians and practice leaders navigating today’s documentation demands.

Medical Necessity is assuming even more importance as the crux of medicine with the increased focus upon the healthcare delivery model transitioning from Fee-for-Service to Fee-for-Value. An inherent challenge in decisions of medical necessity is the inherent subjectiveness of determining whether the care provided meets medical necessity. Determinations of medical necessity are fluid, with different requirements for different third-party payers. The concept of medical necessity spans the entire spectrum of healthcare whether Medicare has Local Coverage

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

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.

What many CFOs are being told: “Clinical validation denials and DRG downgrades are the result of egregious, overaggressive payers who ignore official coding guidelines and arbitrarily challenge diagnoses like sepsis, acute respiratory failure, and metabolic encephalopathy.”

Any clinical documentation integrity initiative must embrace the concept of proactivity versus reactivity, rejecting the reactive tendency of complacency and content. Proactivity facilitates and supports achievement of measurable meaningful improvement in physician documentation that best serve’s the patient’s and all relevant healthcare stakeholder’s needs for accurate and complete communication of patient care. Referring to proactivity, I subscribe to

Clinical documentation improvement has evolved over the last ten years with the advent of the electronic health record and the ability to use natural language processing and other key software to enhance the overall efficiencies and effectiveness of medical record chart reviews. This facilitates the identification of opportunities for diagnoses reporting, hospital acquired conditions and patient safety indicator clarifications. As a whole the profession has not kept up

Effective physician communication of patient care serves a wide array of different purposes in the overall scheme of healthcare delivery, the most important consisting of facilitating fully informed coordinated patient focused quality outcomes-based cost-effective care for the patient. The American College of Physicians sums it up nicely when it comes to the primary purpose of clinical documentation in an article published in the Annals of Internal Medicine position