The Importance of CDI for Healthcare Providers
What is CDI?
Clinical Documentation Improvement (CDI) is a process used by healthcare providers to review clinical documentation and provide feedback to physicians that improve that documentation. To make it even simpler – Medical Coding 101 says, “You can only code what you can document.” CDI 101 says, “Let’s fill in the gaps of what’s documented so we can code better.” Examples might include questions about coding, quality measures, and overall care management of a patient.
Why is CDI Important?
The Center for Medicare and Medicaid Services (CMS) determines the ICD-10 coding guidelines that affect the reimbursement rate for health systems, and revenue cycle managers are usually worried about those guidelines changing every year. But no matter how CMS may change coding guidelines in the future, the need for and benefits of good documentation remains.
Clinical Documentation Improvement in healthcare is important not only because proper documentation is a major component of the hospital’s reimbursement, but also because quality documentation leads to great relationships with other providers within and outside of a health system. Proper and accurate data sharing are key factors in providing effective patient care.
As healthcare evolves to value-based care, physicians are spending more time on patient care and less on documentation. This could lead to a financial risk for the hospital and health system as the providers’ focus is elsewhere.
This is where an experienced and skilled CDI team can assist the physician workflows by ensuring the clinical documentation matches the care provided. These teams can act as a liaison between the physicians and the health systems’ coding staff by filling in the gaps where documentation is lacking. This is completed through 1) a qualified query process. 2) a conversation onsite, or 3) by phone/email with the physicians.
Consider Remote CDI
With today’s technology, Clinical Documentation Improvement workflows are no longer limited to only hospitals who can afford onsite CDI nurses. Smaller regional hospitals or even large health systems looking to consolidate their CDI workforce, can now take advantage of a remote team. CDI nurses can communicate securely through Electronic Health Record (EHR) systems or via email and eliminate the need for face-to-face conversations.
By using this new and improved workflow, physicians are no longer interrupted while caring for a patient and can complete documentation gaps on their downtime. Emailed queries provide the physician clear documentation suggestions and prevent any material being lost in translation. Working remotely can also improve the productivity of the health systems’ CDI teams as these nurses are removed from the chaotic environment and allowed to focus on the review of medical charts. With the ability to communicate via the EHR, the CDI nurses spend less time tracking down the physicians and more time preparing detailed queries or tracking performance management.
To learn more about creating a skilled, remote CDI team and how Shearwater Health can add value to your Revenue Cycle Management, contact us here.