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

CMS under its Medical Review Policy holds its contractors such as the Medicare Administrative Contractors responsible for insuring the payment of provider claims accurately with the primary mission of reducing provider billing errors. The primary goal is to pay the claims correctly the first time around. MACs review clinical documentation to prevent improper payments and choose claims for review based on many factors such as the service specific improper payment rate,

The use of case-mix as a proxy for judging the effectiveness of clinical documentation improvement programs can be characterized as an unreliable imprecise measure of overall success. While case-mix over time can potentially increase over time as clinical specificity in diagnoses capture improves, there are a myriad of contributing factors that control the ultimate calculation of case-mix. Attributing improvement in documentation to increases and fluctuations

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.

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

Clinical documentation integrity programs have evolved over time with its expansion of duties and responsibilities beyond CC/MCC diagnosis capture. The profession has expanded its reach into quality measures such as Hospital Acquired Conditions, Patient Safety Indicators, Core Measures, and other documentation driven reportable measures of care. Fundamental to operational performance of any clinical documentation integrity program is enhancing the physician’s

To best align and integrate with the revenue cycle with lasting sustainable impact, clinical documentation improvement programs must embrace and operationalize processes that achieve real measurable improvement in documentation. Rather than focus upon present Key Performance Indicators measuring outcomes consisting of gross patient revenue, high performing CDI programs achieve accurate, precise and complete documentation that

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.

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.

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.