Clinical Documentation Improvement (CDI): Initiating a Program for Your Practice

Source: Emily Hill, PA, AAPM Coding Consultant
Date: July 11, 2018

CDI has been described as the process of improving healthcare records to ensure improved patient outcomes, data quality, and accurate reimbursement. Historically this has been a hospital-based program that may have important applications to physician practices. Last month, we reviewed the basics of CDI. It is now time to consider the steps of incorporating this into your office-based practice.

As with other types of initiatives, the first step is to assess your current situation. A logical first step for a CDI program is to conduct a base-line audit of your medical record documentation to identify areas that may require improvement or corrections. Most medical record audits focus on accurate CPT and ICD coding which is an important first step in a CDI focused audit as well. Improved reimbursement and reduction in audit liability are some of the goals of a CDI program.

A CDI audit may also investigate documentation processes that impact the quality of the medical record such as the benefits and distractions of drop-down lists, check boxes, macros, and templates. It may also look for redundant documentation and processes that impede the efficiency of the physicians and the clinical effectiveness of the documentation. A review of denials for systemic or provider specific issues is another effective tool for identifying areas that need to be addressed.

An effective program cannot be implemented without staff and physicians who are open and involved in the process. The degree of expertise and readiness of staff to participate in CDI and the understanding and degree of support of the physicians is a critical component of a CDI program.

The steps above provide the beginning of your CDI program. In future newsletters, we’ll look at the next steps for implementing your program including identifying your CDI team. Remember that good documentation is an important step in providing quality patient care and ensuring appropriate reimbursement for your practice.


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