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.

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 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

As outlined in the 2019 Medicare Fee-For-Service Supplemental Improper Payment Data Report, the overall Medicare Improper Payment Rate was pegged at 7.3% translating into $28.91 billion paid to providers improperly. This is a marked improvement from 2018 when the improper payment rate was 8.1% which represented $31.62 billion. The bulk of those improper payments paid by Medicare in 2019, similar to 2018, were attributable to two related

Unfortunately, they don’t teach you how to run a business in medical school. As a result, many physicians struggle to manage the business side of their practice. Entrepreneurial skills are essential if you want your practice to thrive! Are you looking for ways to improve your practice and take your business to the next level? Below, Core CDI shares some tips to help you build a more profitable practice and improve patient satisfaction.

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.

Just like a roadmap or if you use a map direction app such as MapQuest or Waze, one needs a start and end point. The same principle or concept applies to the medical record. There is a definite starting and ending point for a medical record, whether inpatient, observation, office visit, or ED to name just a few settings. Let’s focus upon hospitalization…More than half of patients are admitted to the hospital from the ED so that for all intents and purposes is the starting point.

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

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