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