In today’s value-based landscape, transparency has become the norm and the rightful focus is on the patient.  Complete and precise documentation within the medical record is the key to presenting an accurate representation of the patient encounter and that is where a strong clinical documentation improvement (CDI) program holds value.  There are three top focus areas where a strong CDI program prioritizes its focus for success, and even though each carries its own challenges, partnering with an organization that values integrity and continual learning will help you hold the right key. 

First, in alphabetic order is the focus area of audit.  As external insurer and RAC auditing intensifies in the era of value-based initiatives, it is crucial to take a pro-active approach to accurate billing.  Correct billing begins with complete and precise documentation and accurate code assignment.  Weakness in any one of these three areas (documentation, code assignment, and billing) can greatly affect items such as reimbursement, quality metrics, public reporting, research statistics, and reputation.  On-demand internal audits can provide a temporary patch, but a comprehensive analysis and systematic audit process is a necessity for success in the value-focused healthcare environment.  

CDI audits are becoming the norm and while a check-and-balance system is essential, there is no reason to wait.  While on-demand internal CDI auditing and episodic external auditing has scratched the surface, partnering with a company that can provide a comprehensive analysis and assist with development of a systematic audit process is invaluable to success.

Clinical validation is another hot topic focus area.  It can be described as ensuring support in the medical record for documented conditions by applying clinical standards broadly accepted by the medical community.  While clinical validation can be performed at various points in the mid-revenue cycle, two essential skills – clinical expertise and coding expertise – are recommended for successful clinical validation regardless of when it occurs.

Clinical expertise is a skill that is necessary to verify the clinical evidence for documented conditions as well as to identify opportunities for clarification.  As published medical research is adopted, best practice standards continue to evolve and those who possess clinical expertise understand the clinical standards that are widely accepted by the medical community.   The coding expertise skill is utilized in CDI during the record review as potential documentation opportunities are identified.  The significance of official guideline, classification and coding clinic knowledge is invaluable in bridging the gap between documentation and code assignment.

Staffing your department with CDI professionals that are skilled in both clinical expertise and coding expertise is invaluable for clinical validation

Last, but by no means least, is risk adjustment, where its value lies in the ability to identify those conditions which place the person at risk for maintaining or improving their current health status. Team work is an underlying theme in risk adjustment because value based care endeavors to apply a more holistic approach to healthcare.  The challenge here is in an organization viewing itself as an isolated entity – considering risk adjustment in a silo – with the peril being a patient’s health status not being adequately addressed along the continuum.  Partnering with a company that has a solid reputation in both the inpatient and outpatient environments is the first step to success in risk adjustment initiatives. 

The outcome of focusing on these areas will be a successful CDI program that places the patient first while promoting integrity in documentation, thus presenting CDI as a vital mid-revenue cycle process. 

Is your CDI program directing its efforts to these top focus areas as it should be?  MedPartners has the expertise to find solutions to your mid-revenue cycle management questions.

Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP

2015 ACDIS CDI Professional of the Year

CDI Education & Compliance Manager

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