What is CDI in Healthcare: Maximizing Revenue Through Clinical Documentation Improvement Strategies and Best Practices

Clinical documentation improvement was first introduced in the U.S. around 2005 as part of the move toward a value-based healthcare system.

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The overarching principle of value-based care is that hospitals and physicians are paid based on patient health outcomes—not simply the number of beds in a facility or how many patients are seen each day.

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With incentives to increase the effectiveness and reduce the costs of medical treatment, value-based care makes sense for all stakeholders in the healthcare system. However, to successfully operate within this system, providers must be hypervigilant about maintaining detailed medical records that capture the full complexity of each patient treated.

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Even outside of values-based arrangements, demonstrating performance and eligibility for reimbursement requires an ever-increasing amount of ancillary information in addition to the primary diagnosis and treatment provided (eg., social determinants of health, secondary diagnoses, and post-discharge outcomes).

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To maximize revenue and keep up with the competition in this environment, many providers are now turning to clinical documentation improvement (CDI).

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In short, CDI in healthcare involves a set of practices and processes designed to enhance revenue and quality of care by improving documentation practices.

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In this article, we’ll explain everything providers need to know about CDI. Plus, we will cover how healthcare-specific business process outsourcing (BPO) providers, like Pharmbills, can form an important part of your CDI strategy.

What is CDI in Healthcare?

Clinical documentation improvement in healthcare can be defined as:

A systematic process designed to enhance the quality, accuracy, and completeness of medical records.

In most cases, the aim of CDI in healthcare is to improve the standard of entries into an electronic health record (EHR) in real time.

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To achieve this goal, organizations often employ clinical documentation specialists. 

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A CDI specialist is an internal or external staff member who works with physicians and healthcare clinicians to educate and assist them in getting the patient entries into an EHR correct the first time around.

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For this reason, CDI in healthcare is often described as a collaborative process, where CDI specialists and clinicians work together for improved outcomes.

Key Components of CDI

The exact makeup of a CDI program will vary between providers. However, most CDI implementation strategies include one or more of the following components:

• Concurrent review of medical records - Clinical documentation specialists and clinicians collaborate in real-time to get entries into the medical record correct the first time.
• Streamlined query process - Systems designed to reduce the time needed for a coding or medical billing specialist to gather additional information from a physician before submitting a claim or correcting a record.
• Education and training programs - Initiatives and CDI training programs that support providers to improve their documentation skills independent of assistance from CDI specialists.
• Integration with software systems - With the widespread use of comprehensive EHRs, CDI implementation strategies should aim to integrate with existing software solutions used by healthcare providers. Specific CDI software solutions may also be utilized.
• Performance monitoring - Metrics related to compliance, reimbursement, efficiency, patient outcomes, and more should be considered as part of CDI program evaluation.

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When done well, clinical document improvement initiatives can improve processes and provider skills to the point where the need for coding queries and RCM audits are dramatically reduced, or even eliminated completely. 

Why is Clinical Documentation Improvement Important?

CDI plays an important role in several crucial areas related to both the financial performance and patient outcomes achieved by a healthcare organization. It also helps ensure regulatory compliance across the entire patient journey.

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In practice, what clinical documentation improvement best practices aim to achieve is alignment of medical records with the requirements of insurers and funding bodies.

Benefits of Clinical Documentation Improvement

CDI produces benefits in 6 areas that are important to stakeholders throughout the healthcare system.

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1. Ensuring Accurate Reimbursement

Proper documentation is essential for providers to receive appropriate reimbursement for treatment provided and services delivered. This applies in all areas of healthcare and hospital budgeting and revenue cycle management.

Just some of the elements of CDI revenue cycle involvement include:

• Capturing the full complexity of patient cases
• Supporting accurate medical coding and medical billing
• Supporting accurate medical coding and medical billing
• Minimizing claim denials and revenue loss
• Optimizing the healthcare revenue cycle 

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2. Enhancing Quality of Care

Accurate and comprehensive clinical documentation is a core component of delivering high-quality care. 

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Improving patient care with CDI can be achieved on many levels, such as:

• Better communication between providers
• More informed clinical decision-making
• Reduced risk of medical errors
• Improved continuity of care across different treatment settings

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3. Maintaining Regulatory Compliance

Following clinical documentation improvement best practices assists providers in meeting the various conditions involved in healthcare regulatory compliance. 

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CDI can help individual clinicians and organizations by:

• Ensuring documentation requirements are met for quality reporting
• Supporting accurate reporting for value-based care initiatives
• Demonstrating compliance with accreditation standards
• Minimizing the risk of audits and penalties

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4. Improving Clinical Quality Measures

Quality measures are becoming increasingly important in healthcare. Values-based care models frequently provide significant financial incentives for providers who can demonstrate the consistent provision of high-quality care. Plus, organizations that collect this data can use it to support funding applications and marketing efforts.

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Clinical documentation improvement helps organizations to:

• Capture and record relevant quality indicators
• Provide reports to payers and funding bodies
• Demonstrate the effectiveness of care
• Participate effectively in quality improvement initiatives 

5. Strengthening Data Integrity for Research

Accurate and comprehensive medical records are crucial to research efforts involving clinical care delivery.

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CDI has been identified by researchers as being important because it:

• Provides accurate and reliable data for clinical studies
• Enables the collection of high-quality population-level data
• Improves predictive analysis for patient care
• Reduces the resources involved in collecting information for research

6. Supporting Legal Protection

In medicolegal issues, patient-level clinical documentation is often seen as the single source of truth. 

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CDI in healthcare can provide important protection to providers by:

• Ensuring records accurately reflect the care provided
• Giving a sound rationale for clinical decision-making
• Minimizing the risk of outside evidence being brought into a claim
• Providing peace of mind that clinicians always have adequate records

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Now that we’ve provided a comprehensive overview of why CDI is important, let’s take a look at some best practices for how organizations can implement effective CDI strategies.

Best Practices for Clinical Documentation Improvement

Below is an overview of proven practices for implementing and maintaining a successful CDI program. 

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Information in this table is drawn from both practical experience and research on CDI best practices for physicians, nurses, and allied health professionals.

Clinical Documentation Improvement Best Practices

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Upon seeing the above list of clinical documentation improvement best practices, some providers become concerned about how they will fund the additional staffing resources involved in many of these measures.

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An approach gaining traction is the use of healthcare business process outsourcing (BPO) providers.

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This strategy, sometimes also known as staff augmentation, involves utilizing highly skilled offshore talent who are available at a fraction of the cost of local employees.

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Such an approach enables healthcare providers to quickly realize the financial benefits of CDI, providing a strong financial ROI on a relatively modest outlay for additional staffing resources.

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To find out how BPO services could help your organization, please contact the team at Pharmbills today.

Integrating CDI with Electronic Health Records (EHR)

EHR integration with CDI isn’t just a nice thing to have—these days, it’s essential.

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Modern comprehensive EHRs are involved with virtually every aspect of the revenue cycle. They handle prior authorization, insurance claims, accounts receivable and payable, and more.

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Simply put, unless you can integrate clinical documentation improvement strategies with your EHR, there is a real risk that you will not achieve any benefit for healthcare revenue management from this important task.

7 tips for achieving good EHR integration with CDI

Here are our top tips for how organizations can make CDI easy by integrating it into EHRs.

1. Embed CDI tools directly within the EHR interface
2. Create automated prompts and alerts within the EHR to encourage good documentation practices
3. Engage CDI specialists to create custom templates that capture all required data
4. Integrate documentation query workflows into the EHR
5. Provide electronic clinical decision support tools to assist clinicians with their documentation
6. Ensure that CDI systems are compatible with existing or planned EHR workflows
7. Utilize automated reporting and analytics capabilities within EHRs to track performance against relevant KPIs

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Remember, CDI in healthcare in modern practice environments must always be integrated into the EHR to be effective.

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The vast majority of clinical documentation is completed electronically these days. So there really is no way to implement clinical document improvement without it becoming part of the EHR.

The Role of Technology in CDI

With administrative burden being recognized as a widespread issue across the healthcare sector, it’s more important than ever to utilize technology to streamline as many components of clinical documentation as possible.

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This is especially relevant for CDI initiatives, which if not properly implemented, run the risk of adding yet another administrative task for already overloaded clinicians to complete each day.

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Fortunately,several recent technological advances can streamline clinical documentation improvement.

Technology to Assist with CDI

Here are some of the most promising technologies to reduce the administrative burden involved in CDI initiatives:

• Artificial Intelligence (AI) - AI-powered technologies such as machine learning and natural language processing (NLP) are already revolutionizing the way healthcare clinicians complete documentation and how data is collected and analyzed. NLP-based tools, such as ambient listening technology, have reached the stage where they can handle basic and even more complicated documentation tasks just from “listening” to a patient interview. 
• Computer-Assisted Coding - Accurate medical coding is one of the most important components of clinical documentation improvement. Coding is the shared language that physicians, insurers, researchers, and funding bodies use to communicate about healthcare on both individual and broader levels. Historically, coding has been done by medical coding specialists. However, computer-assisted coding is now able to handle many coding tasks independently. This has the capacity to greatly enhance both the efficiency and accuracy of coding. 
• Analytics and Reporting Tools - Previously, a significant cost involved in CDI in healthcare was the human resources required to collect, analyze, and report on data. While some human oversight is still required, modern EHRs are increasingly equipped with powerful analytics and reporting tools, which can integrate seamlessly with both quality-focused and CDI revenue cycle initiatives.
• Mobile CDI Applications - While having on-site clinical documentation specialists is incredibly helpful, this is not always viable for providers due to cost and logistical issues. Much like how modern technology has enabled care to be delivered from anywhere, mobile CDI applications allow clinicians and CDI specialists to effectively work together even when not physically in the same location.

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The points above provide a good overview of the current state of technology and clinical documentation improvement. However, with the rapid pace of new developments, we expect these technologies, and new discoveries, will continue to transform the sector in the foreseeable future.

Common Challenges in Clinical Documentation Improvement

Despite its many benefits, there are several common challenges with implementing CDI initiatives in healthcare organizations.

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Below are the barriers we see most often, along with potential solutions.

Physician Resistance

Challenge: With the American Medical Association running a campaign to reduce administrative burden, clinicians may be resistant to any changes to documentation processes they perceive will add to their workload.

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Solution: CDI in healthcare must be implemented in a strategic and inclusive way. Plan workflows around CDI initiatives carefully before they are unveiled, ensuring they are as efficient as possible. Education campaigns and training can also improve physician buy-in.

Resource Constraints

Challenge: Implementing a CDI program of any size involves an investment in skilled personnel and often technology. Some providers are not convinced of the ROI delivered by clinical documentation improvement.

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Solution: Compare the costs and reported benefits of several CDI providers before committing to an ongoing contract. While some organizations will require on-site services, contracted BPO services are sufficient for many healthcare providers to realize the full quality and financial benefits of CDI.  

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Changing Regulatory Requirements

Challenge: Frequent changes in healthcare regulations, coding standards, and billing requirements can make it difficult to maintain compliant documentation standards.

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Solution: Implement flexible CDI systems that can be changed and updated with evolving regulations. Consider partnering with a specialist or utilizing high-quality CDI software solutions to ensure your documentation standards are always compliant.

Balancing Quality and Productivity

Challenge: If CDI initiatives upset the balance between quality and productivity, overall outcomes may suffer and CDI could be abandoned altogether.

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Solution: Focus on high-impact documentation elements that significantly impact patient care and reimbursement in your organization. Always conduct a cost-benefit analysis for any additional task clinicians are asked to complete. Plus, utilize technology to improve the efficiency of documentation wherever possible.

The Future of Clinical Documentation Improvement

With the increasing involvement of AI and technology in the healthcare sector, clinical documentation improvement is poised to evolve at a rapid pace in the coming years.

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Below are our predictions for 3 significant evolutions in the future of clinical documentation improvement.

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1. ‍Advanced AI and machine learning integration
   The integration of AI and machine learning into healthcare clinical and data systems is already moving at a rapid pace, which we expect will only continue. 
   
   Big developments are likely to occur in the automation of clinical documentation (with integrated CDI). Plus, seamless access to real-time data about CDI-related KPIs will become common place.

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2. Shift toward outpatient CDI
   So far, values-based care has primarily been focused on inpatient care, as this is the most costly form of treatment and management.
   
   However, we are already seeing some payers implement performance-based care with community and primary care providers. As this expands, CDI in healthcare is likely to play an increasingly larger role in outpatient care.

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3. Focus on social determinants of health
   Social determinants of health (SDOH) already feature heavily in population-level healthcare initiatives. We expect that SDOH-related factors and outcomes will increasingly be incorporated into funding models for clinical healthcare.
   
   This will impact CDI in healthcare because organizations will be required to identify, treat, and measure social factors related to the health of individuals. These outcomes will be included in funding guidelines, requiring organizations to address SDOH to receive optimum reimbursement.

Summary

Aiming to both increase the effectiveness of medical care and reduce the costs of treatment,  clinical documentation improvement plays an integral role in the modern healthcare system.

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Particularly in values-based funding models, the accuracy and completeness of patient records directly influences reimbursement for care delivered.

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As a result, one of the best practices for providers to maximize revenue in the current environment is to have robust processes to ensure medical records capture the full complexity of each patient treated.

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Without this, insurers and funding bodies may deny or reduce payments for care delivered. Plus, organizations risk missing out on increasingly lucrative value and performance-based payments.

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To ensure your organization remains profitable and competitive, it’s important to have an effective clinical documentation improvement program. 

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By using clinical documentation specialists and smart software solutions, a CDI program will help you achieve better outcomes and realize the full financial benefits of CDI.

To find out how Pharmbills delivers affordable solutions to improve revenue, enhance patient outcomes, and support CDI initiatives, please contact us today.