What is Clinical Documentation Improvement And How Does Carepatron Help this?

Essentially, clinical documentation improvement (CDI) refers to the process of improving clinical notes. Clinical documentation serves a variety of purposes, including tracking a patient’s progress, protecting against legal situations, and allowing for insurance reimbursements. Given the important role they play in working as a healthcare professional, CDI programs are now being implemented in hospitals and private practices. 

CDI programs fundamentally focus on improving clinical documentation, coding, and reimbursement. An effective clinical note should be complete, consistent, and accurately reflect the professional judgment of a clinician in relation to their client’s health. The impacts of a CDI program within your practice will not only benefit clinical outcomes, but will decrease the likelihood of rejected claims and lead to a generally improved process of reimbursement. Research on clinical documentation audits has revealed common areas of concern within medical notes, including a lack of specificity, clinical judgment, and review of diagnosis. To combat these errors and ensure the clinical documentation of your practice will benefit your patients and protect you in legal and insurance situations, it is highly recommended that you implement a clinical documentation improvement program.

Clinical documentation improvement programs attempt to improve the process of translating medical records into coding data that is then used for reimbursement, disease tracking, medical research, and report cards. CDI is important for a variety of reasons, including:

• Informed decision-making: The medical treatment of a patient often spans across a number of healthcare providers, departments, and facilities. To ensure that the patient is receiving the most appropriate type of care, communication between these individuals needs to be consistent and effective. Good clinical documentation can greatly improve continuity of care, provide healthcare businesses with the confidence that they have all the information required to make informed decisions.
• Reimbursement: The process of receiving reimbursement can be long and complicated for healthcare practices. One of the most effective ways of ensuring that this process occurs efficiently and without complications is by having accurate patient data. CDI programs help minimize the errors that can occur in coding data, ensuring that you are reimbursed for your services in a timely manner.‍
• Improve the quality of care: Fundamentally, achieving the highest quality of care for your patients should be the number one priority when operating a healthcare business. Essentially, CDI helps to ensure that the details of a session with a patient are documented accurately and that the information provided within an electronic health record (EHR) correctly reflects the services administered. Ultimately, CDI will guarantee that all healthcare providers are equipped with the relevant information, allowing them to elevate their quality of care.

Regardless of what field of healthcare you work in, clinical documentation is at the heart of every single patient encounter. Trends in the healthcare industry in the US are indicating that reimbursement denials are steadily increasing, reflecting the growing complexity of the medical billing process. As these changes become increasingly noticed by healthcare businesses, we are also beginning to see a rise in the number of CDI programs implemented into practices. The impact of CDI on healthcare is becoming more comprehensive, improving patient quality of care and positively impacting certain situations, including:

• Underpayments: As insurance denials are increasing, and the rate of underpayment steadily grows, more and more healthcare practices are searching for a way to effectively improve their medical coding process.‍
• Outpatient care: A significant issue causing denials and rejections often occurs in outpatient care situations. When physicians bill a medical service with the incorrect location of the service, Medicare typically reimburses the overhead facility a much higher amount than the physician. This issue is exacerbated by the possibility of Medicare red-flagging a physician’s billing error.

Clearly, constantly working on improving your clinical documentation is not only in your best interest as a healthcare provider, but it will positively impact patient outcomes. Implementing a CDI program into your practice can educate your physicians on the best way to record clinical notes, and decrease any errors or inaccuracies that can occur when creating patient coding data. You may also want to  evaluate methods used by your physicians. As the use of EHR (electronic health records) becomes increasingly popular, it is extremely important to ensure the software you use is suitable. Finding the right type of software for healthcare practices that optimizes your clinical documentation can be overwhelming, but we are here to help you. 

Carepatron offers fully integrated, HIPAA-compliant healthcare software that can help you streamline your clinical documentation process and automate medical billing and coding. To ensure your notes are accurate and effective, Carepatron offers a variety of useful formatting templates, including SOAP and DAP. Once written, these notes can be stored electronically, using cloud-based technology, guaranteeing that they are both accessible and highly secure. Furthermore, as the insurance and reimbursement process grows in complexity, it has never been more important to limit the errors within your claims. Carepatron’s medical billing and coding features can alert you to any detected inaccuracies or missing information, as well as generate invoices, reminders, and receipts with only a few simple clicks. With Carepatron, your clinical documentation is guaranteed to be successful and you can look forward to streamlining the billing process and receiving timely payments.

Conclusion

Clinical documentation improvement programs are being incorporated into healthcare practices at a growing rate. These initiatives recognize the importance of having good clinical documentation processes, in relation to reimbursement, protection, and improved quality of care. CDI largely begins by observing and analyzing the systems you have and reaching an informed decision about whether these need to change. The advancements in healthcare technology that we have seen in recent years can come into play, particularly if you recognize certain areas of improvement for your practice. With advanced software, your business will be able to streamline its clinical documentation and medical coding processes, ensuring that you are receiving proper reimbursement for your services. Managing the complicated administrative aspects of a healthcare practice can be largely simplified by implementing software that will support CDI, benefiting both you and your patients.

Further Reading:

• Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians ‍
• The Future of Clinical Documentation