Maximize Clinical Documentation Improvement Potential for ICD-10 and Beyond

In this installment of our ongoing ICD-10 Education Series, we’ll discuss opportunities to improve clinical documentation improvement (CDI) programs as part of preparations for ICD-10 and beyond.

Information is driving change in the way health care organizations provide care for patients and streamline business practices. The amount and quality of medical information available to stakeholders along the care continuum creates the opportunity and necessity to better utilize the data to drive better results.

The good news is, more widespread adoption of health IT has brought with it an explosion in the volume of medical data, along with tools to access it. At the same time, health care providers face new challenges in ensuring complete, accurate capture of diagnoses and procedures rendered in patient care, along with the documentation to back it up. Hospitals fear getting a handle on these critical ingredients to billing, compliance and quality measurement initiatives, will only grow moreShely O'Laughlin difficult with the transition to ICD-10, which dramatically expands the central classification system for health care services.

Clinical documentation improvement (CDI) programs address potential physician documentation deficiencies within the greater EMR landscape. Traditional CDI programs are driven by a team of documentation specialists reviewing a sampling of medical records to identify opportunities for clinical clarity, or to fill in gaps in the medical record. Manual CDI efforts have some limitations, however, including:

  • CDI specialists are limited by the number of medical records they can review
  • Many records subjected to CDI review do not need documentation improvement
  • Some physician queries will not receive a response
  • Quality and timeliness of response with retrospective queries is questionable

Health organizations implementing traditional CDI programs are seeing improvement in the specificity and clinical clarity of medical records. However, many are now looking to leverage computer-assisted coding technology to improve the efficiency and effectiveness of their efforts. For example, automating preliminary clinical records review processes enables hospitals to expand CDI reviews to all cases, in real time, and helps CDI specialists focus on cases with the greatest opportunities.

The result? More complete clinical documentation throughout the patient encounter, more consistent and specific diagnoses and procedure codes, and more accurate coding and reimbursement. By enabling hospitals to achieve improvements in these areas, Optum’s CDI 3D can play an important role in easing the transition to ICD-10 and protecting revenue.

In a webinar on October 9, we’re reviewing more advanced methods for evaluating the return on investment for CDI programs, including the CDI Value Compass and measures for Physician Adoption and Engagement, Clinical Revenue Cycle Performance, and Quality Management.


Shely O’Laughlin, Vice President, National Solution Leader for ICD-10 and Clinical Documentation Improvement

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