Clinical documentation improvement in the health care industry

Refining quality, compliance, and integrity of value based care

​Clinical documentation improvement (CDI) can provide the high-quality data the health care industry needs. Here are 10 steps to improve your CDI program.

Documentation requirements

As the delivery of health care and reimbursement methodologies evolve, the importance of a holistic clinical documentation improvement program becomes evident. Requirements of clinical documentation and accuracy of data are essential in achieving quality and cost-saving outcomes, regardless of place of service or health care setting.

The Medicare Access and CHIP Reauthorization Act (MACRA) accelerates health care's transition to value-based payment models by financially motivating physicians to manage more of their patients under risk-bearing or coordinated care contracts. For Medicare physician reimbursement, there are two separate paths under MACRA: Advanced Alternative Payment Models (APMs) and Merit-Based Incentive Payment Systems (MIPS). Both are dependent on appropriate clinical documentation to capture accurate risk adjustment scores.

Risk adjustment methodologies, such as the hierarchical condition category (HCC), impact documentation practices and requirements. They also have an effect on reimbursement and require continuous documentation of all chronic conditions to be reported on a yearly basis for the patient population—regardless of care setting—in order to properly estimate the population's risk score.

10 steps to more accurate documentation

The following 10 steps can be considered to help provider organizations leverage inpatient CDI capabilities and address the increasing demand for accurate clinical documentation in outpatient and clinic settings:

  1. Plan ahead and implement sooner
  2. Analyze current policies and procedures
  3. Re-evaluate the current state of your CDI program
  4. Identify synergies between CDI needs in inpatient, outpatient, and clinic settings
  5. Determine if the right technology is available for operationalizing the outpatient and clinic CDI programs
  6. Understand and prepare for the impact of the changing health care operational environment
  7. Secure talent for the outpatient and clinic CDI programs
  8. Determine performance measures for the integrated CDI program
  9. Educate providers, clinical documentation specialists, coders, and other clinical professionals
  10. Identify strategic leadership and stakeholders to rectify and fill any identified risks/gaps

Ongoing data demands

The importance of accurate and complete clinical documentation will continue to grow across care settings and provider groups. As multiple regulatory and operational changes in the current health care landscape rely on data from clinical documentation, provider organizations will need to establish outpatient and clinic CDI programs that are tuned to the care setting and prioritized based on the organization’s strategy to operate in the new environment. Health care providers should:

  1. Create strong alignment and common leadership—at the highest level, not necessarily at the operational level
  2. Focus on quality and compliance risk—as the stakes grow, so does the need for an effective CDI program
  3. Review different CDI integration models and consider how to tackle challenges across organizational boundaries

Finally, with the introduction of patient safety indicators, MACRA, and other value-based reimbursement models, the focus of health care shifts to factors such as quality of care, clinical outcomes, population risk, and cost savings. Risk-adjustment payment methodologies rely heavily on historical data to predict health care costs based on the relative risk of the patient population.

CDI can be the mechanism to provide the quality clinical documentation and data needed for health care providers to meet the ongoing data demands for validation of quality of care.

Learn more about clinical documentation programs.

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