Clinical Documentation Improvement

CDI function is to fulfill various demands like the best health care practices, processes, technology, people, and joint effort that is carried out between health care providers and medical billers. These demands advocate the completeness, precision, and validity of documentation of different providers to transaction code sets (for example, ICD-10-CM, ICD-10-PCS, CPT, HCPCS) endorsed by the Health Insurance Portability and Accountability Act.

Clinical documentation improvement (CDI) is simply the process of assessing and improving healthcare record documentation such as Healthcare details, patient health events, clinical status, and office visits in Electronic Health Records[EHRs] as coded data and more, for improved health care outcomes, data quality, and accurate reimbursement. 

It captures various events of patients, right from admission to discharge, along with diagnosis, treatment and resources used during their care with high level accuracy and completeness. Therefore the documentation provided is complete, detailed, and accurate, to avoids ambiguity, and ensures the best communication between the healthcare providers.

All these tasks are accomplished by CDI specialists who assure the physician’s documentation to be more complete and exact. A well-furnished healthcare documentation simplifies the healthcare process. Thus improve clinical documentation, medical coding, reimbursements, efficiency of a CDI program and reduce denials.