Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the
Health Insurance Portability and Accountability Act
The Health Insurance Portability and Accountability Act of 1996 (HIPAA or the Kennedy– Kassebaum Act) is a United States Act of Congress enacted by the 104th United States Congress and signed into law by President Bill Clinton on August 21, 1 ...
in the United States.
The profession was developed in response to the Centers for Medicare and Medicaid Services (CMS) Diagnostic-Related Group (DRG) system in 1983 and gained greater notice around 2007 with CMS's transition to Medicare-Severity Diagnosis-Related Groups.
With the expansion of risk-adjusted value-based payment and quality measures and increasing accountability by regulatory agencies, CDI now impacts at least 20 different models affecting payers, facilities, and providers.
CDI professionals act as intermediaries between
Inpatient coders who translate diagnoses into data and healthcare providers and nurses. As many clinical coders don't have patient care backgrounds, and healthcare providers might not realize the importance of accurate documentation, the CDI professional serves to make the connection between these two groups.
CDI professionals should be familiar with
Medicare Severity DRGs (MS-DRG) ICD-9 to ICD-10 coding.
The Association of Clinical Documentation Integrity Specialists (ACDIS), part of Simplify Compliance, LLC, is a provider of integrated information, education, training, and consulting products and services in healthcare regulation and compliance. ACDIS provides the Certified Clinical Documentation Specialist (CCDS) and CCDS-Outpatient (CCDS-O) certifications, CDI boot camps, online learning, books, and webinars.
The Association for Integrity in Health Care Documentation (AIHCD) offers a C-CDI certification. The American Health Information Management Association (AHIMA), which also offers the certified documentation improvement professional (CDIP) credential.
Healthcare documentation serves as a legal document, validates the patient care provided, facilitates claims processing, coding, billing and reimbursement, and facilitates quality reviews.
See also
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Clinical coder
A clinical coder—also known as clinical coding officer, diagnostic coder, medical coder, or nosologist—is a health information professional whose main duties are to analyse clinical statements and assign standard codes using a classification ...
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Electronic health record
An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings. Records are shared throu ...
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Health care
Health care or healthcare is the improvement of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health profe ...
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Health informatics
Health informatics is the field of science and engineering that aims at developing methods and technologies for the acquisition, processing, and study of patient data, which can come from different sources and modalities, such as electronic hea ...
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Health information management
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Health information technology
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Hospital information system
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References
{{Medicine
Health care management
Medical records