AH216 Week 7 Discussion
Clinical Documentation Improvement (CDI)
Physician
documentation is the source by which the coder begins to select the correct
diagnosis and procedure codes. There has been a lot of discussion for
physicians to improve their clinical documentation.
Research Clinical
Documentation Improvement (CDI) related to ICD 10 and indicate how this
movement benefits the clinical coding specialist /medical coder in their day to
day work.
Expert Solution Preview
Introduction:
Clinical Documentation Improvement (CDI) is a process that healthcare organizations use to ensure the documentation in the patient’s health record accurately reflects their clinical status and treatment. In this discussion, we will be exploring the benefits of CDI related to ICD 10 and how it benefits medical coders in their day-to-day work.
Answer:
With the implementation of ICD 10, there has been an increased emphasis on clinical documentation improvement. The main goal of CDI is to ensure that clinical documentation accurately reflects the patient’s condition and treatment to support accurate coding, quality metrics, and reimbursement. Thus, CDI helps clinical coding specialists/medical coders in their day-to-day work in several ways.
Firstly, CDI helps to ensure that the diagnosis codes accurately capture the patient’s condition. This process can also highlight any documentation gaps and inconsistencies that may require clarification from the physician. By improving documentation standards, it reduces the need for coders to engage in constant back and forth with the physician in verifying information.
Secondly, CDI improves the accuracy of the procedural codes. Accurate documentation ensures that the medical coder assigns the appropriate codes, reduces the chances of denied claims, and improves the overall quality indicators of patient care.
In conclusion, clinical documentation improvement through CDI is crucial for ensuring accurate coding, improving the quality of care and reducing the risk of denied claims. The main benefit to medical coders’ day-to-day work is that it promotes accuracy and reduces time spent verifying information.
