Clinical Document Processing

Clinical Document Processing

Clinical Documentation Improvement (CDI) services to assist our clients in providing documentation in the medical record that is complete and accurate. Our CDI tools and education positively impact the quality and quantity of physician documentation in the medical record. Since clinical documentation is the primary driver for a hospital's case mix index (CMI), every hospital can benefit from a CDI program that properly reflects the acuity of the patients the hospital treats. Hospitals implementing clinical documentation position themselves well for recovery audit contractor (RAC) expansion, pay for performance, expansion of quality indicators, present on admission (POA), value-based purchasing, and the growing number of publicly-available comparative scorecards.

Our CDI programs are focused on clinical documentation at the point of service while the patient is still in the hospital. CDI programs are guided by official coding guidelines and pertinent governmental and regulatory requirements. We tailor the CDI program to the specific health system to ensure support of the physicians and the non-physician clinicians. The program incorporates principles of physician professional fee documentation, coding and billing, as well as hospital-based principles.The goals of the CDI program are to ensure clinical documentation: Drives appropriate code selection for accurate reimbursement, Supports high-quality care, Reflects patient acuity levels, Is accurately and compliantly captured at the point of service, Meets JCAHO standards for clinical documentation, Reduces risks from incomplete or unclear documentation, Provides accurate data for Medicare and other quality indicators and hospitals.

Clinical documentation improvement service, consistent with the client hospital's goals, involves the creation of a structure within the hospital that is responsible for educating, monitoring and ensuring the documentation provided by healthcare providers in the organization is of the highest quality. While the attending physician or hospital's documentation is of ultimate importance for coding and reimbursement purposes, documentation from all clinicians caring for the patient must meet the definition of high quality documentation. CDI program follows official coding guidelines and pertinent governmental and regulatory requirements. CDI program is tailored to the specific hospital or health system to ensure support from physicians and non-physician clinicians. Our CDI education and data analysis customized solutions include CDI Assessment - Initial medical record assessment to identify the best opportunity for documentation improvement. CDI Reassessment - Review of existing CDI program, Clinical Documentation Specialist (CDS) Education and Shadowing, Our comprehensive CDS education program and peer-to-peer on-unit real time education and assessment of the documentation specialist's/case manager's proficiency.