The Role of CDI in Healthcare

From improving public health and quality of care to minimizing overhead costs and ensuring a stable revenue cycle, proper documentation is essential for nearly every aspect of the healthcare industry. Its importance will continue to rise as payment models increasingly rely on value-based metrics. 

As critical they are, the requirements placed on providers to generate properly documented medical records can put a heavy burden on clinicians, hindering their ability to deliver quality patient care. A recent survey demonstrated this trend, as 36% of physicians said they spend more than half of their time on administrative tasks related to patients’ electronic health records (EHRs) — and 72% expect that number to rise. 

Enter clinical documentation improvement (CDI): the process of reviewing medical records and documentation for completeness and accuracy. CDI aims to improve both patient care and administrative operations by optimizing documentation practices, all while reducing the burden placed on clinicians. 

From the patient’s perspective, the result is elevated engagement, greater satisfaction, and higher-quality care. From the organization’s perspective, the result is fewer claims denials, higher profitability, and less of a burden on clinicians — a win-win-win for all parties involved. 

In this article, we’ll take a look at the role CDI plays and how it can benefit the patient, the practice, and the provider. We’ll also explain its importance for proper revenue cycle management (RCM) and then list some strategies on how you can ensure your CDI efforts are successful.

What Is CDI?

A patient’s medical records serve as a repository for all of their healthcare information, summarizing their clinical status. By rigorously inspecting a patient’s health records and identifying any gaps in the existing body of knowledge, clinical documentation improvement helps deliver a clearer picture of the patient’s health. 

Simultaneously, CDI clarifies the exact scope of all medical services rendered to the patient. This enables medical coders to submit accurate claims to payers, and it also helps organizations receive adequate reimbursements. 

While CDI provides clarity on a patient’s condition as a whole, its scope is primarily confined to data generated during the patient’s visit, or shortly thereafter. Possible items that a clinical documentation specialist (CDS) might check for include:

• Accuracy
• Precision
• Completeness
• Consistency
• Legibility
• Timeliness

By examining these factors, CDI helps create a more circumspect view not only of the patient’s health status but also of the services rendered so that organizations can be compensated accordingly. 

Why Is CDI Important in Healthcare?

All medical documentation plays a critical role in healthcare. The healthcare industry relies on proper documentation from both a patient care and a revenue management standpoint. 

The Role of Accurate Clinical Documentation in Patient Care

Without proper documentation, patient care suffers. Accurate documentation can have a direct impact on the patient’s quality of life, while inaccurate documentation can result in negative health outcomes — and even the loss of life. This list is not exhaustive, but inadequate documentation may result in: 

• Physician errors
• Overlooked allergies or medical conditions
• Miscommunication
• Incomplete patient history
• Missed prescription refills

At best, subpar documentation can leave patients feeling frustrated that their care team is failing to understand their medical condition. At worst, poor documentation practices can lead to medical errors such as incorrect operations, or even critical oversights that harm a patient’s health. 

Regardless of how severe the outcome may be, CDI can help. For example, when CDI specialists review a patient’s chart, they may identify aspects of their condition that had previously been overlooked. They may also spot conflicting clinician reports, helping to prevent errors before they ever arise. In either case, the careful examination that CDI entails helps identify missing pieces on the patient’s health status and empowers clinicians to deliver better care in the process. 

CDI’s Impact on Revenue Cycle Management

CDI doesn’t just pertain to patient care. By fully articulating the scope of all services rendered, CDI can improve a healthcare organization’s efficiency, reduce its liability, and stabilize its revenue cycle management. Some of the main ways that CDI can benefit an organization’s RCM include:

• Fewer claims denials: By thoroughly explaining the patient’s condition and how they were treated, CDI conveys to payers the reason for and scope of the services that were provided. This reduces the likelihood of a denial. 
• Faster payments: The delays caused by denied claims can destabilize revenue cycles, preventing organizations from receiving their payments on time. CDI resolves this problem by ensuring that medical records are complete so that claims are more likely to be approved in a timely fashion. 
• Higher reimbursement rates: CDI allows medical coders to translate all of the data within a patient’s health record into a billable code. This helps ensure organizations receive accurate reimbursements that reflect all of the treatments they provided. 

CDI Strategies for Success

Once organizations understand the many benefits it offers, they may want to implement CDI as quickly as possible. They may hastily begin searching for CDI software, seek out a provider that offers CDI services, hire educators to give their staff CDI training, and take other steps before strategically planning their implementation. 

While each of those steps is an important part of the process, establishing an efficient CDI system requires more planning than that. A better approach is to evaluate your people, technology, and processes, identifying existing strengths and opportunities for growth. The following tactics can help you get started. 

Implement Standardized Workflows for Chart Reviews

It’s neither feasible nor welcome to query a clinician every single time a question arises regarding a medical record. If you want your CDI system to gain traction on your team, you’ll need to devise a standardized workflow to help decide when a chart should be queried. This may entail establishing protocols that determine when to consult with clinicians, deciding how often charts will be audited, and more.

Organizations such as the American Health Information Management Association (AHIMA) offer a variety of resources to help providers seeking to optimize their medical workflows.

Leverage Data Analytics to Identify Trends

As technology becomes more intelligent, organizations of all types will be able to extract sharper, more actionable insights from data they never knew was available before. This is especially true within the healthcare industry, where many CDI software solutions have built-in analytics. From capturing unstructured data to identifying potential discrepancies, these analytical tools enable team members to spot trends that could improve your interoperability and take your organization to the next level. 

Hire and Train CDI Specialists With Strong Clinical Knowledge

Even with the right tools in place, a CDI system is only as strong as the people behind it. Your implementation efforts won’t go far without a clinical documentation specialist. Trained in both healthcare and medical coding, CDI specialists have both clinical and coding knowledge, allowing them to bridge the gap between the two. 

CDI specialists are usually registered nurses (RNs) who have some background or certification in medical coding, but they could have other backgrounds as well. Other possibilities include medical coders who have obtained their CDI certification but have less experience than an RN. The key is to find someone who can reasonably understand a patient’s medical condition by viewing their chart and can translate that knowledge into the proper code. 

Provide Ongoing Training for Your Staff

Even with a qualified specialist, implementing an effective CDI framework requires all hands to be on deck. Clinicians will need to be informed on how their documentation practices can improve, and medical coders will need a clear understanding of which services can be billed. 

To ensure that all team members are exercising best practices, your CDI management team should provide regular training. Bodies such as the Association of Clinical Documentation Integrity Specialists (ACDIS) offer opportunities for both CDI training and CDI certification, keeping your team at the industry’s helm.

Develop Trust and Respect With Stakeholders

For your CDI framework to be a success, you’ll need buy-in from all parties involved. That means establishing trust and respect among clinicians, coders, clinical documentation specialists, and the rest of your team. And building that trust entails convincing clinicians that CDI can lighten their workload, rather than making it heavier.

Provide Regular Reports to Leadership

As with all components of healthcare operations, effective CDI management is a must, and leadership will need periodic reports on how the project is faring. This means conducting chart audits at a consistent frequency, evaluating physician report cards on a regular basis, and identifying areas for growth.

Foster Collaboration With Other Departments

Working together with other departments is a key benefit of CDI in healthcare, as it facilitates collaboration between teams. Take full advantage of this benefit by having a healthcare provider conduct a concurrent review of the chart so that they can catch errors that others may have missed. 

Let Clarity Clinical Documentation Help

Given the modern healthcare industry’s dependence on proper documentation, having an effective CDI workflow in place is less a matter of luxury and more so a matter of operational hygiene. Organizations with effective CDI frameworks have fewer claims denials, receive payments more promptly, are at a lower risk of noncompliance, and deliver higher-quality care to their patients — with less of a burden on their providers. 

At Consensus, we deliver intelligent healthcare solutions that can aid your organization’s CDI efforts. One of our tools is Clarity, an interoperability solution that’s designed to securely facilitate patient data exchanges across multiple platforms, making it easier to shore up the gaps in your CDI efforts. We offer many other tools that are designed to ensure compliance and improve profitability, all while elevating patient care, so request a demo of our products today.