Over the past decade, an increasing number of hospitals have implemented clinical documentation improvement (CDI) programs. Unsurprisingly, financial considerations are a key driver behind this trend. Increased scrutiny of health care costs by public and commercial health plans translates into increased focus on ensuring complete, accurate capture of diagnoses and procedures rendered in patient care, along with the documentation to back it up.
While documentation is crucial to ensuring proper billing and payment for medical services, new challenges facing health care providers are poised to bring even greater attention to the importance of CDI. For example, clinical records integrity will be critical to emerging quality measurement and compliance programs.
As a result, hospitals are investing in CDI programs, hiring specialists to review charts and identify conditions that were diagnosed or treated, but can’t be coded and billed due to insufficient documentation. To-date, CDI has been a largely manual process, but technology solutions are stepping in to improve their efficiency and effectiveness.
The good news is there is a growing body of helpful information available to health care leaders exploring CDI programs and technology. We recommend the following:
- Executive Insight magazine: Overcoming Obstacles to Complete, Accurate Documentation for ICD-10
- HFMA Education Report: The Right Documentation Strategy: Improving Your Clinical and Financial Performance
- Optum White Paper: Supercharged CDI — NLP, intelligent workflow and CAC revolutionize CDI program at UPMC
Kyle Pak is senior vice president and general manager of the Financial Performance Solutions business at Optum. He oversees efforts to bring Optum’s innovative technology solutions, services and revenue cycle management expertise to help hospitals and integrated health delivery systems achieve better, more sustainable financial performance.