The Strategic Value of Clinical Documentation Integrity in an Increasingly Complex Healthcare Ecosystem

Hospitals and physician groups understand the role Clinical Documentation Integrity (CDI) plays in the delivery of high-quality care and reimbursement. However, they may not realize how the shift to value-based care has changed that dynamic. CDI is no longer just a process of adding notes to the electronic health record; it has become a more strategic initiative with far-reaching implications.

The convergence of clinical care, documentation, and coding processes is vital to appropriate reimbursement, accurate quality scores, and informed decision-making to support high-quality patient care.1

Key Benefits of an Optimal CDI Program


Clinical documentation ensures data regarding exams, symptoms, diagnoses, medications, tests, treatments, and other patient care factors are captured in the electronic health record (EHR). Having this information in a single place provides a holistic picture of a patient’s health journey for any clinician who treats the patient at any facility connected to that EHR. This enables better collaboration and communication between providers and helps improve outcomes by reducing gaps in care, drug interactions, conflicting care plans, and suboptimal outcomes.

The following are four additional critical benefits that an optimal CDI program can provide.

Clinical documentation is necessary for the accurate reporting of quality measurements across five groups: Mortality, safety of care, readmission, patient experience, and timely and effective care.2 These measurements are then factored into Star Ratings that determine an organization’s performance level and reimbursement.

Regulatory compliance, particularly around Medicare-based MS-DRG and hierarchical condition category payment models, has become increasingly complex, significantly impacting clinical documentation and coding, processes that have become highly burdensome and time-consuming. These manual processes are also prone to error, which can lead to denials, excessive claim rework, increased administrative burdens, poor cash flow, delayed reimbursement, unnecessary write-offs, and surprise patient bills.

Poor coding quality can also result in payer audits, takebacks, and penalties. Therefore, building an effective CDI program can help mitigate financial risks associated with inaccurate or incomplete documentation.

Another benefit of optimal clinical documentation, and one that is often overlooked, is its effect on an organization’s profile score and, thus, its brand reputation. Ratings organizations use a wide array of complex factors to determine a hospital’s quality ratings but are primarily focused on clinical outcomes, patient safety,  and patient satisfaction—all of which are reflected in clinical documentation.

Organizations such as Healthgrades and the Leapfrog Group publish ratings on their websites, making them accessible to the public. With a simple Google search, consumers can access hospital ratings as well as provider reviews, which can help them determine where to get their care. Rating sites are also used by clinicians, including medical students, residents, nurses, and physicians, to determine where they might want to work. In an age of clinician shortages, having a positive reputation can give an organization a competitive advantage when trying to attract and retain new talent.

An organization’s ability to attract and retain top talent is a reflection of high-quality care and safety standards—both of which are reflected through accurate clinical documentation.

Medical errors are a leading cause of accidental death in the U.S. While actual numbers are difficult to calculate, some studies suggest it could be as high as 250,000 a year.3 Of those, medication errors are one of the most common.4 This includes prescribing the wrong medication or the wrong dosage or failing to consider medication interactions. High-quality clinical documentation can reduce medical errors by ensuring information in the patient’s record is accurate and complete.

Research shows that the quality of clinical documentation is reflected in the quality of patient care, patient safety, and the number of medical errors.5

Implementing and Optimizing a CDI Program


Developing and implementing an effective CDI program begins with educating billing staff and clinicians. They must understand how their attention to detail and accuracy impact documentation quality, reporting, outcomes, revenue, and brand reputation. Regular review of actual documentation, key performance indicators, and industry benchmarks should be included in this effort.6 Registered nurses, physician champions, or seasoned coders adept at clinical documentation are great options for leading the reviews. These individuals can also act as regulatory specialists, monitoring regulatory changes and payer updates and implementing updated guidelines to comply with new requirements.

The Role of Technology and Data Analytics in CDI


Another essential element of a highly effective CDI program is implementing CDI software, such as computer-assisted clinical documentation technology. These technologies can streamline workflows while also detecting and flagging documentation errors and missing information. This helps coders and documentation specialists identify problematic trends so they can be proactively addressed.

CDI technology is also beneficial in its ability to perform detailed analyses of clinical documentation and can be used to track and measure documentation quality and identify improvement opportunities.

Artificial intelligence (AI) is another invaluable tool for CDI as it can automate many aspects of documentation, thereby reducing errors associated with manual data entry. CDI technologies can also transcribe physician voice recordings and enter that data into the EHR. AI-enabled voice recognition technologies can capture relevant information during a patient visit and input that information into the EHR in real time.

Because AI-assisted clinical documentation can recognize complex medical terminology, how it’s used, and in what context, it can create highly detailed, accurate documentation. Clinicians can review the notes, make changes, and then sign off on the documentation, saving them from having to spend evenings and weekends entering data into the EHR.

The Bottom Line

High-quality clinical documentation is a vital conduit for quality outcomes, accurate reimbursement, reduced medical errors, and a positive brand reputation. Leveraging education and CDI-assisted technology is essential to success. For organizations that lack the resources necessary to optimize or implement a CDI program, partnering with industry experts can help. Conifer Health is an excellent choice.

Conifer Health’s Clinical Documentation Integrity solution supports critical reporting for clinical quality and accurate and appropriate reimbursement. Our solutions include the following:

  • Operations management and consulting
  • Customized physician education, training, and engagement
  • Workflow and technology optimization
  • Quality audits and skills assessment
  • Documentation reviews that pinpoint errors, leakage, root causes, and improvement opportunities
  • Machine learning and AI to improve accuracy and reduce the need for human intervention

Conifer Health has more than 150 physicians, nurses, and credential coders certified in complex billing, with a 7% to 10% case mix index. Our results include:

30%

improvement in physician query agreement rate

96%

average physician response rate

98%

accuracy average query

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