6 steps to implement a CDI program

Clinical documentation initiatives that incorporate clinicians within revenue cycle operations can help hospitals better prepare for population health management.

Powerful analytics tools will fail to generate actionable insights into a hospital's patient population if its raw clinical data is incomplete or flawed. Ensuring comprehensive and accurate clinical documentation is a strategic priority for all hospitals hoping to thrive under population health management models.

As health systems continue to assume a greater volume of risk-based payments, clinical documentation improvement will begin to shift from a revenue-enhancement mechanism to a function organized around capturing quality and managing high-risk patients. Progressive health systems are establishing CDI programs that support care management and standardize documentation patterns to capture payments tied to achieving certain quality thresholds. More comprehensive and accurate clinical documentation shows treatment was administered according to medical necessity, which can improve quality measure reporting to CMS.

Here are six steps to implement an effective, long-lasting CDI program.

1. Analysis and interpretation. Before investing in CDI programs, hospitals should take time to analyze current clinical documentation, coding and revenue cycle performance. This can help hospital leaders target cash leakage, problematic quality reporting or insufficient clinical documentation.

2. Assemble a CDI team. Effective clinical documentation improvement programs employ a variety of specialists and staff members to influence meaningful change.

  • CDI specialists. Hospital administrators should consider recruiting CDI specialists to lead documentation improvement teams. Successful CDI leaders typically have either nursing, pharmacy or health information management experience, possess working knowledge of state, federal and payer-specific requirements for coding, documentation and reporting and are CDI certified through the American Health Information Management Association.

  • Physician champion. As creatures of habit, physicians often resist change to their traditional routines or workflows. Recruiting physician leaders for CDI programs can help facilitate inter-department communication and encourage adoption efforts among clinical staff. Effective physician champions are motivated to drive hospitalwide change and have a strong rapport among clinical staff.

  • Cross-functional team. CDI leaders should assemble staff members from across all coding and documentation departments, including health information management, revenue cycle, clinical, administrative, case management and utilization review.

3. Choose a model. Different CDI models target different parts of a hospital's documentation life cycle. Hospitals can incorporate multiple models within their CDI initiatives depending on those areas that merit attention. Hospitals should develop and establish CDI programs that focus on health information management and coding, case management and continuity of care and quality reporting issues.

4. Choose a CDI tool. Hospitals can chose from a myriad of software platforms geared toward clinical documentation improvement, case management and computer-assisted coding to support CDI program efforts.

5. Establish employee training programs. CDI leaders and staff members should develop education programs to introduce hospital employees to best practices in documentation and coding. Physician training programs, for instance, should include mandatory CDI orientation for new clinical staff, encourage ICD-10 coding knowledge and share data on problematic diagnosis-related groups.

6. Record benchmarks to show return on investment. Sharing data on performance metrics with clinical, HIM and coding staff can help motivate employees to embrace change. By monitoring key performance trends, CDI leaders can also demonstrate the measurable value of CDI investment to hospital administrators. Helpful benchmarks to monitor include case mix index, number of days not final billed accounts, claims denials, targeted DRG rates and present on admission indicators.

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