Amplifying Revenue with Clinical Documentation Improvement Strategies

Clinical documentation is a compilation of information and records pertaining to a patient’s medical care. This may include symptoms, medications, procedures, and examinations, among other things. Gathering and maintaining all these records gives healthcare practitioners a greater understanding of their patient’s health status, allowing for more informed decisions and, ultimately, better clinical outcomes.

It is critical to constantly improve healthcare documentation since timely and correct documentation is essential to the performance of healthcare organizations. Improving medical records reduces costs while increasing output.

Many hospitals and clinics utilize a clinical documentation improvement team due to the huge time savings that may be realized. To improve healthcare documentation and reporting for your healthcare organization, you must look at areas that may undermine excellent documentation.

Clinical Documentation Improvement (CDI)

Clinical documentation improvement (CDI) is the process of reviewing medical record paperwork for accuracy and completeness. The CDI includes evaluating the disease process, diagnostic outcomes, and any potential record gaps.

In the context of CDI, the term “clinical documentation” typically refers to records kept by a provider or clinical member of staff in charge of the patient’s care during a physical visit, though reports from diagnostic procedures, tests conducted, and specialist consultations may also be included in a patient’s medical record.

Why is CDI Important?

The significance of clinical documentation improvement (CDI) for a healthcare provider cannot be overstated. The various healthcare changes that have been implemented have only helped to underscore the importance of ensuring utmost accuracy for all documentation at all times. The following are the benefits of clinical documentation improvement (CDI):

• Ensures greater revenues as a result of more accurate medical coding and fewer errors that could have resulted in lower revenue.
• No delays due to faulty medical documentation; thus, timely refunds are guaranteed.
• Aids in identifying the correct risk adjustment scores, which can lead to better treatments and outcomes for the patient, as well as an improvement in the hospital’s reputation.
• Maintains consistent compliance with rules as a result of accurate and complete documentation.
• Assist healthcare providers in smoothly transitioning from the fee-for-service model to the pay-for-quality or value model, bringing in more patients and enhancing clinical outcomes in the long run.

How can Clinical Documentation be Improved?

The following are some strategies for improving clinical documentation in 2023:

• Accurately gathering patient information

You must collect complete demographic and insurance information during the patient screening phase. The acquisition of reliable patient data is the foundation of a robust claims procedure.

It is critical to obtain a copy of the patient’s insurance card. When working with repeat patients, it is best practice to get a replica of the health insurance card at each appointment and compare it to the information in your system. Claims are routinely denied in offices that do not follow this approach as their patient demographic data is not right.

If your clinic detects a sudden rise in denials or a trend of regular denials, the intake procedures may be faulty. Giving your front desk personnel feedback after many claim denials allow them to discover the underlying cause, make the necessary improvements, and collect the data required for future clean claims.

• Expand education

Some healthcare practices may assume that new employees understand documentation standards, although this knowledge can constantly be enhanced. According to the Healthcare Financial Management Association, healthcare organizations will benefit from systematic clinical documentation training for new and existing employees.

The education process should be ongoing and adjusted whenever new electronic health record software is introduced. Staff members will be well educated in proper documentation practices and able to rapidly address any flaws if training is a continuous component of a practice’s day-to-day activities.

• Increase patient access to EHRs

It is unavoidable for physicians to make documentation errors from time to time, and who better to catch these errors than patients? According to the ACP report, patients frequently discover mistakes that could be significant in optimizing treatment when they get access to their medical information.

Allowing patients to access their EHRs through online portals may help practices improve their documentation and reap the benefits of full and accurate notes. As this type of information access is critical, many practices are likely already working on incorporating the technology.

Wrapping Up!

Healthcare organizations recognize that organizing complicated data is critical to offering a great patient experience. Clinical documentation must be accurate in order for patients to have a positive health experience. If patient information is not recorded correctly and comprehensively, errors will occur, which can have severe consequences for patients and physicians. These documentation errors, however, can be eliminated with clinical documentation improvement (CDI) services.

Our CDI professionals at 24/7 Medical Billing Services are AAPC certified. As a medical billing and coding company, we will offer exact medical billing and coding services to strengthen healthcare organizations from the ground up. We will create suggestions and quality resources based on comprehensive inspections of a client’s current billing and coding systems to assist clients in obtaining the most effective CDI service possible.

See also: Choosing The Right Medical Billing Service Provider: Key Considerations For Healthcare Practices