Clinical documentation improvement, oftentimes shortened to just CDI, is a crucial part of making a practice run efficiently. During virtually every step of the reimbursement cycle, having clearer documentation can improve both claim accuracy and overall reimbursement. As such, it’s no surprise that many practices of all specialties are looking to improve their CDI. Thankfully, ICD-10monitor has released several goals for those looking to up their documentation game in the new year.

  • Examine previous data – Understanding how things have worked in the past is a great first step for improving them in the future. In particular, look at bundled payments and Medicare shared savings programs, and consider reaching out to experts in these areas to better understand how they affect clinical documentation.
  • Understand how CDI affects performance data – ICD-10monitor recommends “get[ting] outside your department and help your colleagues in clinical quality determine the root cause of lagging performance.”
  • Adopt a population-centric approach – This can make it easier to improve the quality of data used to monitor population health management and risk adjustment.
  • Determine if your practice could benefit from outpatient CDI – Many departments such as emergency services are not typically the focus if CDI initiatives, meaning that they are prime targets for improvement.
  • Understand risk adjustment from both CDI and coding perspectives – In particular, reviewing Hierarchical Condition Categories (HCCs) will help clarify exactly how coding and clinical documentation can benefit each other.
  • Know how technology can impact clinical documentation – As in many other cases, electronic medical records (EMRs) can cause issues with CDI. By understanding the shortcomings of these programs, you can better prepare your practice for avoiding them.

Though these goals aren’t guaranteed to fix all your documentation issues, they can be a great way to understand more about your practice and which areas would benefit from CDI. If you don’t already have a clinical documentation improvement plan in place for 2018, there has never been a better time to begin one.