What is the Purpose of a Clinical Documentation Improvement (CDI) Program?
A Clinical Documentation Improvement (CDI) program is a process designed and implemented to achieve accurate and thorough medical record documentation. Why are CDI programs needed? In many ways, the use of the Electronic Health Record (EHR) system has eased the burden on providers and hospitals of navigating the administrative duties surrounding patient care and claim submission. However, the responsibility of medical record documentation — the entry of clinical information concerning care rendered to a patient — will always remain with the medical provider. To help providers succeed in this task, Everest’s CDI specialists are responsible for reviewing a patient’s medical record to ensure documentation reflects the specificity of current conditions to allow for accurate coding of the patient’s health status.
Benefits of a CDI Program in the Inpatient facilities
An inpatient CDI program can have a positive financial impact on healthcare facilities by increasing the accuracy of coding and billing, which leads to more accurate reimbursement. In addition, proper claim submissions can prevent costly consequences from unfavorable audits. Consequently, the role of CDI in claims processing is essential for both initial reimbursement and preventing negative reviews by authorities.
As a CDI specialist, it’s important to be knowledgeable about both federal regulations and payer requirements. This way, you can ensure that your hospital’s documentation will stand up to scrutiny from auditors. For example, the Office of Inspector General (OIG) is responsible for identifying instances of fraud, waste, and abuse in medical claims submitted to the federal government. By familiarizing yourself with the OIG Work Plan, you can be prepared for any potential audits.
One of the biggest problems in healthcare documentation is that it doesn’t always support coding. This can lead to overbilling and incorrect diagnosis codes. For example, in July 2020, the OIG released an audit that found hospitals had overbilled Medicare by $1 billion for claims that included severe malnutrition diagnosis codes. In the 200 claims reviewed,164 of them should have had other forms of malnutrition or no malnutrition diagnosis codes at all. The OIG recommended that Medicare collect the overpayments from providers where possible. This is where a CDI specialists can help. By reviewing documentation and training providers and coders on the documentation required to support malnutrition diagnoses and codes, we can help ensure that patients have accurate diagnoses in the medical record.
How CDI can help maximize revenue?
One benefit of inpatient CDI programs is that they can help prevent unsupported diagnoses from being reported on a claim. But it’s also important to ensure that all clinically supported conditions are reported, for the sake of inpatient facility reimbursement. To really understand how a CDI program can benefit an inpatient facility from a financial perspective, you need to know how Medicare’s DRG payment system works. Many non-Medicare payers have a similar system. DRGs (diagnosis related groups) are just what they sound like: groupings of diagnoses that are related and affect care during an inpatient stay. The patient’s principal diagnosis and up to 24 secondary diagnoses, including comorbid conditions (CC) or major comorbid conditions (MCC), determine the DRG assignment.
How CDI Can Improve Patient Care
A CDI program can have a significant positive impact on inpatient care. By identifying and addressing potential clinical documentation deficiencies, a CDI program can improve the overall quality of patient care. In addition, a well-run CDI program can also lead to increased reimbursement for the hospital, as well as improved communication between the care team and the health insurance provider.
The inpatient CDI program not only has a significant financial impact, but also improves the overall well-being of the patient. Poor records can negatively impact patient care in a healthcare facility by affecting continuity and quality of care. The concurrent review of documentation by the CDI specialist enhances communication between all providers involved in the patient’s care, which may reduce the length of stay for the patient.
Similarly, a CDI program can help reduce avoidable readmissions by improving communication and care coordination between patients and their caregivers at the time of discharge. Payers have taken note of these benefits and created programs to promote them. For example, the Hospital Readmissions Reduction Program (HRRP) reduces payments to hospitals with excess readmissions. In addition to HRRP, CMS assesses a broad set of healthcare activities that affect patients’ wellbeing.
Benefits of a CDI Program in the Outpatient facilities
A CDI program in the outpatient setting can have just as much financial impact as in the inpatient setting. Provider offices rely on a healthy revenue cycle to ensure expenses and salaries are paid, but claim denials or amendments because of improper code submission can be disruptive to the timely receipt of payment for services rendered. The primary focus of a CDI program for physicians in an office or outpatient environment is to help prevent these denials and amendments while also ensuring documentation is complete for clinical purposes.
As an example, the CPT 2021 evaluation and management guidelines for office and other outpatient visits changed from typically requiring key elements such as history, exam, and medical decision making (MDM) to basing the level of the visit on MDM or time. Accurate and specific clinical documentation is essential to proving medical necessity for the CPT® codes submitted on a claim. CDI specialists can play a role in preparing providers and coders for coding and coverage changes that affect documentation requirements, as these E/M changes did. After updates, the CDI specialist can continue to assist by reviewing documentation and claims to validate the diagnosis codes accurately reflect what the provider recorded and support medical necessity for the level of E/M code reported on the claim. If a payer audits the claim later, the medical practice can feel confident they have done their best to be accurate and can share their process with the auditor to prove their dedication to compliance.
The role of CDI extends beyond documentation for services such as office visits, immunizations, and minor procedures in the doctor’s office; patient outcome-based quality services are becoming more meaningful to both the patient and the physician. For instance, if a physician or physician group is eligible to participate in the Merit-based Incentive Payment System (MIPS), which is part of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, positive or negative payment adjustments could be realized based on reporting of high-value, patient-centered care.