As value-based healthcare becomes the norm, strong clinical documentation improvement (CDI) programs are becoming more important than ever.

Value-based healthcare is a healthcare delivery model in which providers are paid based on patient outcomes. The Center for Medicare and Medicaid Services (CMS) is implementing a quality payment incentive program as required by law. Value-based reimbursement models will soon be the norm for fee-for-service payment. In a New England Journal of Medicine survey conducted in July 2018, 42% of respondents think value-based reimbursement models will be the primary revenue model for U.S. healthcare.

However, a complete and accurate medical record is the cornerstone of healthcare reimbursement. That’s where CDI comes in. CDI is the process of improving medical healthcare records to maximize claims’ reimbursement revenue, increase data quality, and improve patient care outcomes. Payers depend on clinical documentation and accurate coding to validate value-based reimbursement.

Clinicians are responsible for entering the required data into the healthcare record. Health information management professionals then extrapolate the documented data from the medical record to report quality information to payers. This is why a strong CDI program has become a substantial prerequisite for organizations in order to assist clinicians in recording the needed information.

Organizations can start a CDI program by identifying areas that will have the biggest impact on quality, revenue, and patient care. Begin with an assessment and then implement an education program not only for clinicians but for coders and CDI staff as well.

Five common areas in which a CDI program can have the greatest impact are as follows:

• Emergency Department
• Physician Practice
• Evaluation and Management Services
• Observation Services
• Hospital readmissions payment reduction

Our revenue cycle team works collaboratively with organizations to design comprehensive clinical documentation programs, transfer the knowledge needed to achieve organizational goals, and provide follow-up services to ensure sustainability.

If you have questions or would like to learn more about what we can do, please contact us.