Clinical Documentation Improvement- or CDI- is a term to describe the overall process of healthcare records improvement. Such improvement will ensure better patient outcomes, accurate reimbursement, and improved data quality. Typically, CDI is a hospital-specific program, but since its importance and effectiveness are recognized, these programs are most often implemented throughout physician practices.
CDI implementation directly impacts many aspects of healthcare: consistency, completeness of records, information legibility, and accuracy of the medical records. Thus, the implementation of a cdi program has a direct impact on medical decision-making and the physician’s clinical judgment.
A cdi program has the primary goal of improving clinical documentation, reimbursement, and the coding process. Regarding reimbursement, effective cdi program implementation reduces claim denials and improves the appeals process through better clinical documentation. Thus, healthcare providers can work with more valuable and complete medical records and much more complete and meaningful patient data and records.
Implementing a cdi program in your practice requires good planning and a powerful strategy. Documentation improvement is a primary goal that instantly leads to improved reimbursement and a highly efficient clinical record database. An efficient cdi program will ensure better communication between the back-office team and physicians. CDI also helps speed up the coding process and will help improve the claims’ overall accuracy. Whenever there is a CDI system that supports a healthcare facility, there are powerful patient care benefits exist.
There are specific certifications and credentials that a CDI team must accomplish. For example, a CDDS- or Certified Clinical Documentation Specialist is an expert who profoundly understands physiology, pathology, pharmacology, and medical coding guidelines. These experts also have the proper knowledge to interpret medical documents and formulate appropriate physician queries. Then a Certified Clinical Documentation Specialist Outpatient- CCDS-O- will know about outpatient CDI- here, we can include clinics, emergency healthcare departments, or physician practices. The primary role of a CDI expert is to aid healthcare providers in achieving accurate and complete documentation.