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Clinical Documentation Improvement Services (CDI)

Health systems can have the best processes, the best people, and the best technology – but if you don’t have the best clinical documentation, none of that matters.

High quality, comprehensive documentation is a must have if your healthcare organization wants to be acknowledged for its good work in the eyes of many healthcare programs including MACRA, ICD-10 and RAC.

The upshot? Your physicians and clinicians need to understand the intricate ins-and-outs of clinical documentation for their specialty. Whether your organization has identified a clinical documentation improvement (CDI) team or has left this within the hands of HIM and case management, you must provide the physician specialty specific continuing education to garner the clinical documentation improvements that can truly help your bottom line. In other words, your healthcare organization needs to go beyond generic training and educate clinicians on the specific ways that clinical documentation can affect denials management and bottom line impact opportunities.

As a consulting firm that, according to the 2016 KLAS® IT Advisory Services Report, excels in a variety of critical metrics (tools and methodology, strategic competency, operational execution and healthcare knowledge and expertise), we can work with your organization to radically improve clinical documentation. Our approach to CDI design addresses the foundational elements of medical necessity, denials management, defensible documentation, and reimbursement while ensuring consistent and complete documentation in all settings. Our CDI expertise covers the needs of physicians, HIM, coding, quality, case management, informatics and information technology. And, through it all, we make sure that we are helping your organization develop an effective patient-centric revenue cycle.

Our Clinical Documentation Improvement services include:

  • CDI Needs and Gap Assessment: Initial analysis of coded medical record data to identify needs for documentation improvement and gaps in current documentation – including pre-admission review, denials management, care management and use of observation services.
  • Existing CDI Program Assessment: Wondering if your current CDI program could use a little help? We’ll review your existing CDI program to identify what is working well, and suggest enhancements with a view toward post ICD-10 compliance, denials management, improved reimbursement, and auditing compliance. This can include planning for expansion to encompass physician provider services.
  • CDI Program Implementation: Implementation of a complete, formal, facility specific CDI Program.
  • EHR Systems Audit: We’ll review your in-patient or Clinic EHR to determine how well the documentation templates and workflows support CDI best practice. The audit assesses gaps for including system screen and query modifications, and identifies enhancements to data structures for regulatory compliance. The scope can also cover Meaningful Use (MACRA), legal record compliance, physician specialty support, efficacy to “tell the patient story,” support for quality data requirements, and HCIS system and discrete data reporting usability.
  • Clinical Documentation Specialist Education and Shadowing: A comprehensive CDS education program with on-unit real time education.
  • Physician Specialty Specific CDI Training: Ongoing training and everyday tools to assist physicians with their documentation requirements.

Jacobus Consulting has helped clients realize sustainable and superior results. See our client success stories and our KLAS® results for more information.

Contact us: info@jacobusconsulting.com or 949.727.0720.