Clinical Documentation Improvement

CDI CDI oh
Why? Because documentation found in health records is crucial as evidence of services provided and the quality of those services.
1. Why? Because third-party payers (yup, that includes Medicare) are looking at documentation more closely to make sure it supports information on a patient's claim, including:
  1. severity and acuity of a patient's illness
  2. the patient's risk of death or mortality
  3. clinical data details necessary for diagnostic and procedure coding, research, patient safety, and quality scorecards
Seven CDI Goals (AHIMA CDI Toolkit)
1. Improve coders' clinical knowledge
2. Promote health record completion during the patient's course of care
3. Identify and clarify missing, conflicting, or nonspecific physician documentation related to diagnoses and procedures
4. Improve communication between physicians and other members of the healthcare team
5. Support accurate diagnostic and procedural coding, DRG assignment, severity of illness, and expected risk of mortality, leading to appropriate reimbursement
6. Provide education
7. Improve documentation to reflect quality and outcome scores

Resource summary

	Created by mc_student over 10 years ago