Global Clinical Documentation Improvement
The clinical documentation improvement(CDI) is a recognized process of improving healthcare information to ensure improved data quality, patient outcomes and accurate representation of patient's clinical status that translates into coded data for proper reimbursement.
- The program can be described as a service that assists providers and facility in obtaining accurate, specific complete, quality documentation
- Reviews are performed concurrently and retrospectively with Accuracy essential for Providing safe, appropriate patient care and treatment
- Identifying documentation issues for Patient safety indicators PSI and implementing Hospital Value Based Purchasing Program (HVBP)
- ICD-10 coding justifying medical necessity of inpatient status and length of stay
- Appropriately reflecting severity of illness and risk or mortality scores
- Reflecting true physician and hospital performance in publicly reported data (profiles)
- Influences consumer perception
Coding & CDI is reviewing medical records both concurrently and retrospectively to facilitate the accurate representation of the severity of illness. That will facilitates improvement of clinical documentation in the medical record to ensure an accurate level of clinical services, appropriate coding of principal and secondary diagnose, complications and Present on Admission POA indicators that drive reimbursement, quality performance metrics, and CMI.
Providing successful clinical documentation improvement (CDI) programs to facilitate the accurate representation of a patient’s clinical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending for research purposes needed by the Healthcare facility.
To be the professional community that improves healthcare by advancing best practices and standards for health information management and the trusted source for clinical documenting improvement, Retrospective Consultation Services, and coding auditing.
Hospitals, Patient & Physicians Advantages
- Driving CMI (Case Mix Index) and reimbursement forward by catching missed Diagnosis Opportunities.
- Accurate reflection of the severity of patient illness
- Accurate calculation of Mortality Index
- Advance calculation of patients approximate length of stay in Hospital
- Improve Hospital-Acquired Condition Reduction Program (HACRP)
- Improve patient care and quality
- Retrospective review before billing process to ensure accurate hospital billing and reimbursement
- Compliance with ICD-10 Coding Guidelines.
- Coding and CDI pay for Performance
- Improve physician’s public profile
Coding & Clinical Documentation Improvement is a service that Facility & Physician can use to help their quality of Care—not how they provide it, but how they project it (in their Documentation)
- Assist providers with documentation requirements and ongoing changes
- Obtain documentation clarification in patient’s chart and help with query responses
- Accurately reflect severity of illness to improve hospital/physician performance
- Help ensure accurate coding and billing by obtaining documentation clarification concurrently and retrospectively
- Reduce post-discharge Coding Queries and Provider deficiencies
- Hospital Value-Based Purchasing Program (HVBP)
- MS-DRG payment adjustment
- Penalty or Incentive
- Pay-for-performance (P4P)
- Claims based – ICD-10 diagnosis codes submitted on claims
Coding & CDI Team are on the front line for accurate Documentation by the Providers Hospital Value-Based Purchasing Program (HVBP)
A hospital’s CMI represents the average diagnosis-related group (DRG) relative weight for that hospital.
It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges.
The Higher CMI reflects the success of Coding audit and CDI program for the hospital.