Decoding Clinical Documentation Integrity’s Influence

By: Ron DiGiaimo, MBA, FACHE, and Ben Adams

​The COVID-19 pandemic has put tremendous financial stress on the healthcare industry and analysts are forecasting that operating margins will be challenging for the remainder of 2021. Procedures such as elective surgeries are being placed on hold as available physical space within the hospital walls is limited. Additionally, longstanding staff shortages continue and likely will increase through 2030.

Industry experts predict the number of healthcare systems currently experiencing negative margins will most likely continue increasing in 2021 and 2022, and the financial stability of all hospitals nationwide will feel significant effects from the pandemic.
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Understanding this, healthcare leaders are searching for new solutions to secure the financial stability of their organizations. Clinical documentation integrity (CDI) is one resource that often goes unutilized but has been proven beneficial in operationalizing cost and quality improvement.

Clinical Documentation Integrity’s Role in Healthcare

CDI is the process of improving healthcare records, ultimately impacting patient outcomes, data quality, and accurate reimbursement. As a system, CDI touches many roles and facets within healthcare, including medical professionals, staff, and healthcare facilities to manage and streamline processes relating to patient health records.

Clinical documentation within a patient’s medical record should capture the type of care provided, in addition to the time and resources spent to provide the care. This is key, as inaccurate documentation of patient symptoms and corresponding diagnoses can result in an inaccurate reflection of actual patient acuity and essential care provided.

In addition to reviewing records, CDI teams craft and facilitate education to broaden the foundational knowledge for providers in all service lines. With the understanding that codes and subsequent coding guidance from CMS most likely will change from year to year, CDI teams proactively broaden their own knowledge and understanding to ensure that required documentation updates are included in additional provider training and that no unintended gaps in documentation occur.

Current Clinical Documentation Integrity Challenges

Our front-line leaders have been battling the pandemic for more than 18 months. They are overwhelmed with the day-to-day pressures of providing exceptional patient care amid chronic staffing difficulties and meeting the threshold for minimal documentation requirements for professional and hospital billing. Clinicians strive to ensure critical elements of documentation are recorded, but this can prove difficult. Sometimes their efforts will fall short given the increasing complexity of patient care.

Amidst more complex patient populations lies the added burden of ongoing coding changes. Every 6-12 months brings code deletions, additions, guidelines, and code revisions, requiring continued education and updated resources. While the timeline is expected, many of the changes come as a surprise. These changes can further strain an already inefficient process or add complications to one that might be currently working well.

Being able to show the ROI of the clinical documentation program is of the utmost importance, but it can also be difficult to accurately depict. Measuring the impact of your program can be challenging since data from outside sources is not provided in real time. In fact, many elements are delayed by months or even years.

The Case for CDI Teams and Education

The benefits of CDI directly contribute to the overall health of an organization. With the growth in data availability and tracking, it is increasingly important for CDI education to become a priority for healthcare organizations.

By utilizing CDI education, organizations are thereby investing in their financial viability, their employees, and the patients they serve. The impact of CDI education and training is beneficial to every aspect of the business — including those receiving care.
To help streamline education, many organizations develop CDI teams or CDI specialists. These associates are trained to not only query providers but to also create education that makes the ever-changing world of coding easier to navigate. The partnership between clinical documentation specialists and frontline providers is essential for a successful outcome.

A well-trained clinical documentation team will be armed with the knowledge of what to look for in the medical record and close the gaps in clinical documentation that will lead to improved revenue and overall higher documentation quality.

When employees are up to date on their education, healthcare organizations experience faster claim submissions, reduced denials, and more accurate reimbursements. These improvements lead to better patient care transitions and increased productivity and cashflow. The role of coding and training clinicians to document completely and accurately is paramount to a healthcare organization’s bottom line.

Given the highly complex and ever-changing regulatory environment, CDI expertise is crucial for the long-term financial health and stability of healthcare organizations. A steady and unwavering commitment to education, competency, and collaboration maintains the underlying fundamentals of data accuracy and continued improvements in medical record documentation.