It’s no secret that medical billing is becoming increasingly complex throughout California and the United States in general, yet one aspect that’s often going unnoticed to mitigate this clinical documentation integrity.

But why is it so important to improve clinical documentation, and how can this actually make a substantial and notable difference in your medical practice?

In an ideal world, you’d always want your medical record documentation to be organized by CDI professionals (Clinical Documentation Integrity specialists) – think of things such as a patient’s clinical status, details regarding treatments, and even diagnosis, too.

Not only does this provide a fairly comprehensive medical record, but quality clinical documentation is also absolutely paramount when it comes to correct coding for medical bills – not to mention making sure they’re reimbursed appropriately and remain compliant with the ever-changing regulations.

Ultimately, this is where CDI programs and a clinical documentation specialist come into play, offering practically invaluable assistance for any small medical practice looking to improve on the basics.

So, throughout the course of this article, we’ll be taking a look at why quality reporting is important and how your practice can harvest its power. Let’s get started!

Understanding Clinical Documentation Improvement

At the core of CDI, it’s basically a process to follow so your practice can enhance not only the quality but the accuracy and specificity of any and all of your medical documentation with the hopes of “guaranteeing” proper coding and billing.

Generally speaking, this serves as the bridge between the healthcare providers, i.e. your practice, and your medical billing team, whether they’re an internal team or an outsourced third-party company, helping to capture the full patient story and accurately reflect the complexity of your services rendered.

The primary purpose of CDI is to ensure that the medical documentation accurately represents the patient’s diagnosis, treatments, and procedures. By capturing all relevant information, CDI helps medical billers submit claims that align with the services provided and comply with coding guidelines.

The Impact on Revenue

One of the main ways in which CDI can impact your revenue is by addressing the missed opportunities you’ve had for proper reimbursement. Whether it’s from incomplete or simply vague documentation, under-coding basically means that you’re not billing for the full scope of services you’ve provided.

Naturally, this results in less revenue which can have a significant impact on your practice’s financial health.

Creating a Clinical Documentation Improvement Program

Now that we’ve established why CDI is so important for your practice, let’s take a look at the ways you can implement a CDI program into your daily operations.

Assess Current Documentation Practices

Firstly, you’ll always want to start by evaluating your current processes for documentation to identify any areas that might need improvement. Here you’ll want to look for things like non-specific or incomplete documentation – even things like the inconsistent recording of diagnosis-related groups.

Doing this in the beginning basically serves as a baseline so you can track your progress throughout the CDI implementation.

Define CDI Goals and Objectives

Next, you’ll want to make sure your goals for implementing this system are actually clearly defined. Do you wish to improve your general coding accuracy and reimbursement rates or simply improve your patient care?

In essence, establishing specific goals in the beginning, will help you know what impact your efforts are actually having.

Educate and Train Healthcare Providers

Not every practice will be able to afford this kind of thing, but effective CDI usually starts with educating and training your current medical staff. Consider conducting training sessions or even workshops for them so you can educate them on the overall importance of accurate documentation.

You might want to train them on specific documentation requirements and coding guidelines or even things like the best practices for capturing the complete patient story.

If your small practice is struggling to find the resources to hire all these additional staff members, let alone spend the time training them, consider partnering with PMN for your CDI needs!

PMN has a record spanning 20 years, aiding small practices, in particular with their medical record documentation, so feel free to get in touch with them at (949) 215-5055 to learn how they might aid your practice. Alternatively, come visit their branch in person at Laguna Hills, Orange County, California!

Implement Documentation Improvement Tools and Resources

And lastly, if they’re available to you, try to leverage technology and available resources to support your CDI program (PMN can be vital for this). Implement things like an electronic health record (EHR) system that can provide you with the templates and prompts needed for thorough documentation.

Though expensive to buy outright, which is why many practices outsource, these systems help to streamline your general documentation process and ultimately ensure compliance with coding guidelines throughout the state.

FAQs

Can Outsourcing Clinical Documentation Improvement Services Benefit My Small Medical Practice?

Understandably so, many smaller practices don’t have the cash flow to invest in the resources required to properly implement a CDI program, making outsourcing a fairly advantageous prospect. This allows you to tap into their specialized expertise, too, ensuring thorough documentation and generally relieving your practice’s administrative burden, which can help for optimizing revenue.

How Often Should I Review and Update My Documentation Practices?

Regular review and updates of documentation practices are crucial. As healthcare regulations evolve and coding guidelines change, it’s essential to stay informed and adapt accordingly, so make sure you conduct periodic assessments and establish a general culture of continuous improvement in your practice.