Cecilia Guardiola, JD, RN, director of CDI provider consulting with Optum360, discusses how documentation quality affects the organization’s performance.

Q: Why should clinical documentation improvement (CDI) be a priority for hospital and health system leaders, and how can financial executives in particular most effectively work with clinicians to improve efforts in this area? 

A: Clinical documentation is an important component of your organizations’ overall strategy because it integrates physicians, quality of care, healthcare economics, and the patient’s healthcare management team. No matter the setting, the clinical documentation in the health record, as designated by the physician provider, is one of the foundational building blocks of our healthcare delivery system today. Only accurate, complete, and consistent documentation can translate into the code-based data and information necessary to capture clinical quality, substantiate medical necessity, and drive revenue integrity. Hence, efforts to improve the quality of that documentation remain a focus for hospital and health system administrators. 

CDI programs are becoming increasingly important under ICD-10 due to the increased specificity and granularity requiring a correspondingly higher specificity in the clinical documentation provided in the medical record. Current CDI programs will be required to modify existing processes and systems to reflect the specificity inherent in the system. The goal of CDI should be to improve the accuracy, completeness, and specificity of clinical documentation through assessment, education, review, clarification, querying, and monitoring of clinical documentation. Additionally, all of these actions must be accomplished without overburdening the clinician provider. If the CDI program is successful, improvements will be seen in care coordination, quality, and severity of illness reporting, pay for performance programs, bundled payments, RAC, other audits, and code-based reimbursement. Although driving organizational change can often be elusive, organizational leaders that focus on CDI can advance both clinical and financial goals. 

Source: Optum360.