Clinical Documentation Improvement– or CDI- is a process that focuses on the improvement of medical records in order to ensure better data quality, accurate reimbursement methods and improved outcomes for patients. CDI programs were implemented across healthcare systems as a main form for reimbursement. However, most physicians experienced the need for additional documentation that would support even more specific ICD codes to improve data collection or the reimbursement process at the healthcare facility.
The ability to collect and record an even greater amount of data had as a direct result the creation of Clinical documentation improvement systems that resulted in a more robust and expanded platform. CDIs are primarily used in hospital settings, but the importance of these programs is nowadays also recognized across physician practices. The main aim of a CDI program is to improve reimbursement, coding and documentation systems. CDI programs have a huge impact on the overall organizational system of a healthcare facility. These programs play a major role in decision making, clinical judgment and the accuracy of a medical record.
CDI programs are also primordial regarding the reimbursement factor. Efficient clinical documentation improvement programs will help reducing denials, thus improving the reimbursement platform as a whole. Meaningful patient information data and access to more useful medical records helps the entire organization work more smoothly and efficiently.
The implementation of a CDI program has multiple benefits. First, it helps standardizing health care across multiple teams. This translates into smoother workflow and better communication. Increasing reimbursements and reducing claim denials is yet another great benefit of implementing such programs. Improving patient satisfaction is also a direct effect of a well working CDI program.
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