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Why and How to Build a Successful Clinical Documentation Improvement (CDI)
Program
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WHY AND HOW TO BUILD A SUCCESSFUL CLINICAL DOCUMENTATION IMPROVEMENT (CDI)
PROGRAM
By AGS Health
June 1, 2023
This article is the first of a three-part series by AGS Health regarding the
value of clinical documentation improvement (CDI). We begin by sharing why and
how healthcare organizations should build a CDI program.
As the first step toward maintaining accurate health data, CDI ensures that the
events of the patient encounter are captured accurately and that the electronic
health record (EHR) properly reflects provided services. Without CDI, a myriad
of issues can impact various factors, including revenue, reimbursements,
compliance, patient experience, and more.
The adoption of CDI programs drives tangible, measurable results in improved
patient care and efficiencies in the revenue cycle. A survey by Black Book found
that 88 percent of hospitals have documented quality improvements and increases
in case mix index (CMI) within six months of launching a CDI initiative, while
more than 90 percent of hospitals with 150 beds or more – all of which
outsourced their CDI programs – reported CDI-related increases in appropriate
income and reimbursements by more than $2.1 million.
With the ongoing shift to value-based care, hospital and physician financial
executives are continuing to explore new ways to use data analytics to support
reimbursement. Evolving CDI initiatives are a natural extension in managing the
transition from volume to value, which requires accurate and concise
documentation of a patient’s health and conditions supported by evidence. CDI
has emerged as a primary pillar of any value-based strategy – particularly when
it is supported by a deep understanding of and ability to demonstrate the ROI it
delivers.
Building a successful CDI program starts with identifying the organizational
pain points that could be eliminated with improved documentation quality. These
may include:
* Potential Financial Impacts (e.g., Denial Rates and Quality or Outcome
Measures)
* CC/MCC (Comorbidity or Complication/Major Complication or Comorbidity)
Capture Rates
* SOI/ROM (Severity of Illness/Risk of Mortality) Capture Rates
* Over or Under-Coding and Severity Levels
* CMI (Case Mix Index) Variances
After identifying the primary pain points, one model for implementing a highly
effective and successful CDI program is the centralized systems/decentralized
specialties approach. It enables the systems, processes, and resources shared
broadly across specialties to be managed by one centralized governing body while
the documentation produced within each respective specialty remains
decentralized. This ensures the documentation is reviewed by true experts in
each area rather than by CDI specialists who do not have – nor can realistically
be expected to develop – the level of expertise required to be optimally
effective within each individual specialty.
The centralized systems/decentralized specialties are peer-to-peer, helping gain
acceptance of CDI while still allowing for a high degree of standardization of
processes and procedures. It can also lower costs related to CDI by opening the
door to near-shore, off-shore, and domestic outsourcing of standardized tasks.
Download our whitepaper, Understanding and Demonstrating the Value of CDI, to
learn how to educate and demonstrate the value of this investment to senior
leadership. Then look for our next article in this series that discusses
measuring the value of CDI.
Download Now
AGS Health
Author
AGS Health is more than a revenue cycle management company–we’re a strategic
partner for growth. By blending technologies, services, and expert support, AGS
Health partners with leading healthcare organizations across the US to deliver
tailored solutions that solve the unique needs and challenges of each provider’s
revenue cycle operations. The company leverages the latest advancements in
automation, process excellence, security, and problem-solving through the use of
technology and analytics–all made possible with college-educated, trained RCM
experts. AGS Health employs more than 10,000 team members globally and partners
with more than 100 clients across a variety of care settings, specialties, and
billing systems.
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