As healthcare providers, you don’t need us to explain to you why clinical documentation integrity is such a crucial part of the overall patient experience – whether that’s for generally streamlining your operations or even just ensuring all of your documentation stays accurate.

Having said that, this is definitely one aspect of medical billing/coding that the practices with larger amounts of resources have an easier time with – and as such, it’s the small medical practice owners that find it the most challenging to implement a proper clinical documentation improvement program (often referred to as a CDI program) given how strapped for staff and time they can be.

Still, this isn’t something you want to gloss over when running a medical practice (regardless of your size) simply because of how big an impact it can have on improving patient care and hospital reimbursement.

So, over the course of this article, we’ll be taking a look at some of the more basic fundamentals of what CDI actually is and how you can improve it within your practice – including how outsourcing your medical billing and coding services to a third party company like PMN can help.

The Importance of Clinical Documentation Integrity

Clinical documentation integrity (CDI) is obviously important for a few different reasons when you need accurate medical records, so let’s break down a couple of these now:

Firstly, and perhaps most importantly, having a CDI program is generally going to ensure that all of the coded data you’re collecting from your patients is actually being recorded correctly. Now, naturally, the main benefit from this is that you’re typically able to provide an all-around better service to your patients, but it’s worth mentioning how much of an impact this can have in diagnosis-related groups (DRGs) and hospital reimbursement, too.

Aside from this, though, quality clinical documentation tends to leave a positive impact on any given patient’s clinical status – given that you and all your physicians are able to make much more informed actions for a patient’s treatment plan when it comes to medical decision making which ultimately means the quality of care is going to be better.

Lastly, accurate documentation is going to make the whole documentation process much smoother in general, so you’re also able to reduce a lot of those errors that might be messing up your claim submission process when getting reimbursed.

Tips for Clinical Documentation Improvement

Staff Training

Generally speaking, the first step to actually improve clinical documentation within your practice is always going to be providing a bit of extra training to your clinical documentation specialists.

Naturally, this can be a bit tricky for some of the small practices out there that can’t always justify the cost, but ultimately, just make sure that all of your CDI professionals know what their job is when it comes to maintaining medical records and generally being up-to-date with all the latest coding guidelines (because they change fairly frequently).

Clear Guidelines

Try to set a few different documentation guidelines and protocols so that your medical staff can stay consistent throughout their work.

Regular Audits

It’s always good practice to audit your medical record documentation regularly so you’re able to take a look at which areas could still do with some improvement.

Outsourcing Medical Billing and Coding Services to PMN

Whether it’s handling your A/R days or even providing you with progress reports, PMN are generally a wise choice when you’re looking for a medical billing and coding partner. Still, PMN also have over 20 years of experience with CDI, so let’s walk through a few reasons why they might be able to help your practice:

Expertise

Among the rest of their specialties, PMN have plenty of clinical documentation integrity specialists as part of their team – all of which are well-versed when it comes to medical documentation and CDI programs in general.

Efficiency

Even outside of the CDI programs, outsourcing your medical billing and coding needs to PMN is generally going to streamline the rest of your practice’s operations, too – ultimately letting your physicians save time and move back to focusing on the quality of care they’re providing your patients.

Compliance

As mentioned earlier, staying compliant with all the latest regulations and coding guidelines in California can be complicated because of how regularly they are updated, so working with PMN means your practice is always going to remain on the right side of the law.

So, if you’d like to learn more about the difference PMN can make in the more administrative side of running your medical practice, we recommend getting in touch by calling (949) 215-5055 or even booking a face-to-face appointment at their office in Laguna Hills, Orange County, California!

FAQs

What Are The Potential Risks of Inaccurate Clinical Documentation For My Practice?

Naturally, when any of your documentation is inaccurate, it’s going to lead to a host of different issues – whether that’s general non-compliance, being reimbursed the wrong amount, or even just compromised patient care. Aside from this, it has the potential to end up in legal or financial problems, too, so CDI programs and accurate documentation are a pretty important part of healthcare.

How Can My Practice Ensure It Remains Compliant With Changing Regulations and Coding Guidelines?

Given how frequently documentation guidelines tend to change, you’ve got to be looking at continuously educating your staff and performing routine audits if you want to stay compliant. Of course, outsourcing to a specialized provider like PMN is also going to help since they’re dedicated to maintaining compliance with industry regulations.