Healthcare team standing together in a clinical environment, led by a nurse in blue scrubs, representing collaboration in clinical documentation and patient care.
Documentation is a core function in any medical practice or healthcare organization. It is critical to accurately document symptoms, diagnoses, and treatments to deliver the most effective patient care.
The same documentation is also used for billing purposes. Payers require complete and accurate medical documentation and the associated coding before they approve claims. Errors or missing data can lead to delays or denials that require appeals and slow reimbursements.
Clinical documentation improvement systems and clinical documentation improvement specialists can ensure billing accuracy for better healthcare revenue cycle management.
What Is Clinical Documentation Improvement (CDI)?
Clinical documentation improvement (CDI) is a process of reviewing medical records to make sure they are both accurate and complete, as well as compliant with billing rules set by the Centers for Medicare and Medicaid (CMS) and private insurers.
The immediate benefit of improved clinical documentation is high-quality care. A robust, up-to-date, and accurate electronic health record ensures that all providers involved in a patient’s care share a clear understanding of their medical history and treatment plan. This reduces the risk of miscommunication or incorrect information that can delay or compromise care. Providers can coordinate patient care transitions in real time, without waiting for information to be sent between offices.
CDI systems also improve revenue cycle management. Accurate, complete, and fully supported documentation can improve several elements of claims processing:
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Fewer Denied Claims: CDI overcomes common medical billing challenges by reducing coding errors and providing the necessary information to payers. This increases timely reimbursements and reduces the likelihood of claim denials that require labor-intensive appeals.
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Increased Reimbursements: Collecting all the relevant medical details creates a more complete picture of the care patients are truly receiving. Staff can more accurately reflect the full scope of care when filing claims, and avoid under-billing. This results in higher reimbursement totals, ensuring that healthcare organizations receive accurate payment and improves their long-term financial viability.
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Audit Readiness: Accurate records are vital during any audit. Robust CDI allows healthcare organizations to confidently demonstrate compliance during audits and reduce the risk of penalties arising from inaccurate billing practices.
What Does a Clinical Document Specialist Do?
A CDI system typically relies on Clinical Documentation Specialists (CDS). Clinical documentation improvement specialist training tends to be cross-functional, with CDS professionals having both a clinical background and expertise in the medical coding process.
CDS staff review medical records to identify diagnostic findings, procedures, and treatments and determine what documentation might be missing. Their familiarity with clinical practice allows them to recognize the typical diagnosis and treatment pathways for particular conditions. They can then identify additional data both to complete the medical record and be used to support the insurance claim. They can use the EHR system to query the treating providers and gather additional information to fill in any gaps.
Once CDS staff have gathered all the appropriate data, they can properly align billing codes for submission to payers.
How CDI Improves Coding Accuracy and Prevents Denials
CDI practices drive comprehensive clinical documentation in medical records. All details about diagnosis, medical history, lab tests, treatments, and procedures are compiled and evaluated for accuracy before submitting claims to the payer. Comprehensive and accurate clinical documentation increases the number of clean claims submitted, speeding up reimbursements and reducing unnecessary denials.
This level of rigorous detail ensures that claims include all relevant codes, preventing under-billing. That factor can be particularly important when billing under systems like Medicare’s Diagnosis-Related Group (DRG) payment system. DRGs are groupings of all patient diagnoses relevant to care during an inpatient stay. This can include the patient’s principal diagnosis and up to 24 secondary diagnoses.
Individual treatment elements during a hospital stay can point to a secondary diagnosis that may not be listed in the patient's chart. For example, the use of oxygen support might signal the presence of an underlying respiratory disorder that falls under a different code, which is the principal reason for the stay. However, since that condition required care during the inpatient stay, it should be billed as a related diagnosis.
Omitting discrete secondary diagnosis codes can lead to under-billing and lower reimbursements than the healthcare organization is entitled to receive. CDI processes capture those details to improve revenue cycle management.
Leveraging Technology for Better Documentation
Technology can support CDI by automating management processes, which saves staff hours spent on document review. Increasing the pace of documentation review speeds up claims processing, and reduces billing backlogs for more efficient revenue cycle management.
Clinical documentation improvement software increases efficiency by utilizing AI tools for medical billing accuracy. The software can review data from an EHR platform, match billing codes, diagnoses, and treatment records, verify insurance details, and flag possible errors before submitting claims.
These same technologies can generate customizable data reports, which can be used to inform future documentation and compliance with healthcare regulations. Over time, these analytics can give a clear picture of how a healthcare organization is improving key performance indicators (KPI) such as clean claims, time to claim approval, accuracy of revenue projections, and outside audit results.
CDI software tools work best when expert CDS professionals can review the data. The software cuts the time needed to evaluate every chart, but nothing replaces the value of staff with clinical experience applying their expertise to the process.
How Puredi Elevates CDI and Revenue Outcomes
PUREDI’s cloud-based revenue management software elevates documentation improvement systems with end-to-end practice management solutions. The system can improve documentation efficiency, provide electronic remittance advice, and automate coding to increase revenue capture and reduce claims denials.
Our system deploys natural language processing (NLP) tools that allow AI to scan medical records and assign appropriate billing codes. The same tools can flag errors or missing information, so CDS staff can query providers for additional details.
Puredi RCM software integrates with electronic health record systems for seamless operations. It creates detailed analytics reports to help hospital decision-makers engage in continual documentation improvement. We offer comprehensive medical billing software demos so you can learn how our solutions will help your practice.
Contact us today to speak with one of our team and find out what Puredi can do for you.
