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The need for Clinical Documentation Improvement in the healthcare industry

The need to document patients’ medical history and treatment processes started as early as the 19th century. The process became more streamlined by the 20th century, and experts started strongly advocating the need for complete and accurate clinical documentation for all patients. Such clinical records not only help the patients and future healthcare providers but are also valuable for medical billing and coding companies to provide accurate bills for services.

Clinical documentation, in simple terms, is the information about a patient’s medical history and care maintained in a medical record. Such records could be a physical file, a local folder on a computer, or an Electronic Health Record (EHR) available digitally.

Clinical Documentation Improvement (CDI) is the process of making the documentation process more efficient and effective so that the information is accurate, complete, easily available, and constantly updated. Many healthcare organizations have started hiring CDI specialists as full-time employees or third-party experts to help improve their documentation process. If you haven’t considered this, then this should be one of your top priorities.

While CDI is vital for a lot of reasons, this blog will only cover its importance for medical billing and coding companies to do their tasks right. Here are reasons you may have to invest in CDI services as a private practitioner or a general healthcare provider.

Your billers will need accurate information about treatments offered and diagnosis. Only then can they bill the payer accurately. Inaccurate billing may lead to two problems – the claims getting denied/rejected or the practice losing money by missing out on billing the complete services offered. Here are two examples of how incomplete documentation can cause problems.

  • In July 2020, an OIG audit report was released stating that Medicare was overbilled by about $1 billion since coders incorrectly assigned a severe malnutrition diagnosis code to other health conditions! Medicare was, in fact, advised to collect these wrongful payments from healthcare providers. Imagine suddenly receiving a request to refund back considerable fees already made by Medicare. In most cases, the money may already have been used by the organization. This is going to be a sudden financial burden that may drown the hospital.
  • Let’s say a patient was admitted for a pulmonary condition and discharged in 3 days. The clinical documentation mentions the initial diagnosis, the primary treatments offered, the discharge summary, and the medical billing and coding company that works for you bills the payer accordingly for $10,000. Let’s say a small detail about the patient being put on respiratory ventilator assistance for a few hours was left behind. If so, the Diagnosis Related Groups (DRGs) change, and you may actually be eligible to submit a claim for $15,000. That’s $5,000 lost because of incomplete documentation.

What happens when you regularly submit improper or over-valuated claims to payers?

Thanks to incomplete clinical documentation, if you end up sending over-valuated or improper claims, your claims rejection and denial rates will increase. If these increase beyond a certain value, you may face unfavorable audits. These are going to get very expensive, with demands of refunds or fines, which can be disastrous.

How effective are medical billing and coding companies in handling incomplete clinical documentation is a question that definitely needs to be asked. Many of these companies invest heavily in technology to improve their billing and coding accuracy. However, if the input (the clinical documentation) is incomplete by itself, then none of these high-end tools are going to matter.

The first step to reviving an inefficient RCM process is to tap on the clinical documentation and correct it.

Who are clinical documentation improvement experts, and how can they help?

A CDI expert is someone who comes with ample coding, clinical, and technological knowledge. As a result, the person or the team can help spot documentation inaccuracies and correct them before the biller starts creating claims.

All medical billing and coding companies need to have such a team to correct the foundation before they promise to adhere to SLAs. Such experts usually analyze the documentation and may know if the entries are wrong or incomplete. Thanks to their clinical knowledge, they may be able to add fine details that complete the documentation.

How to kickstart a CDI program?

A successful CDI program may help in the below ways too.

  • Reduce back and forth queries between physicians and the backend team.
  • Reduce the burden on physicians.
  • Help future medical practitioners get a stronger idea on the patient’s medical history.
  • Help researchers analyze cause-effect relationships and disease progression.

CDI processes are quite challenging as there could be a plethora of errors, miscommunications, information backlogs, and internal issues that could be adding to the inefficiencies. Finding these out and eliminating them one by one may be time-consuming, and unless you hire medical billing and coding companies that know what they are dealing with, you may not be getting the right results.

CDI experts not only help coders pick the right codes for the actual services offered but may also validate the diagnosis codes to know if they actually match the services offered. With a CDI expert around, medical billing and coding companies confidently send out claims without guesswork.

Quintessence actively supports our clients in creating and implementing their CDI strategies. We understand the importance of the right documentation for the practice’s future and for bettering the healthcare services offered. Hence, we use both humane and technological expertise to get this sorted before the organization moves forward with correcting other vitals like high denials rate and low revenue generation.

Incomplete or incorrect documentation could become a silent predator that feeds on the practice’s revenue, leading to increased AR cycles and unnecessary delays in claims moving from encounter to successful reimbursement. Talk to us to know how best to kickstart a CDI program within your practice and set the base right.