Implementing and maintaining an effective and efficient Clinical Documentation Improvement (CDI) program has increasingly become a necessity in recent years for healthcare facilities across the healthcare spectrum, and especially for inpatient facilities such as acute care hospitals and skilled nursing facilities (SNFs).
A successful CDI program has numerous benefits for facilities, that include:
• Improved quality of care resulting from:
♦ Improved communication between providers and other members of the healthcare team
♦ Improved ability to provide awareness and education
♦ Promoting health record completion during the patients’ course of care, which contributes to patient safety
• More appropriate reimbursement for services provided with a reduced need for rebilling – and a reduction in overhead associated with a high volume of rebills
• More accurate quality scores, impacting both facility and providers alike
• Support accurate diagnostic and procedural coding & MS-DRG assignment leading to appropriate reimbursement
• Obtain clinical documentation that captures the patient’s SOI and ROM
• Identify and clarify missing, conflicting, or nonspecific provider documentation related to diagnoses and procedures
• Improve documentation to reflect quality and outcome scores
• And much more
To be both effective and efficient, and to achieve the benefits discussed above, a CDI program must be clinically driven rather than revenue driven and function as an interface between providers & coders designed to promote increased accuracy and specificity of clinical documentation – especially for complex cases. The program should be pervasive, though not competitive, and should involve everyone in a mutual success. While implementing such a program is no easy task on your own, you can leverage MARSI’s years of experience and expertise to train your team(s) and render this task far less daunting. Once implemented, such a CDI program must be maintained, and MARSITraining.com has you covered there as well.
MARSI has been on the forefront of clinical documentation before it was ever even called “CDI”, and we have a proven track record of helping our clients achieve and exceed their goals including:
• Medical records that can stand on their own in defense of a lawsuit.
• A more effective query process in which coders can present valuable clinical questions that the provider can actually understand (rather than using “coder-speak”)
• know they can trust the medical record will provide the documentation necessary to withstand an OIG review. withstand adverse coding and medical necessity audits
• Medical records that actually tell the patient's story.