One of the top priorities for healthcare facilities across the country is effective clinical documentation improvement (CDI) strategies. A successful CDI strategy will enhance your medical record quality, reduce the incidence of incomplete documentation, and increase patient care communication. In addition, improved physician documentation results in an improved case mix index (CMI) and more precise coding specificity and brings in appropriate reimbursement for resources utilized.

Medical billing and coding staffs for health care providers use clinical documentation when evaluating claims. Most healthcare facilities employ clinical document improvement (CDI) specialists to review each patient’s clinical documentation and ensure it is comprehensive to ensure there are no gaps in a patient’s clinical documentation. Clinical documentation improvement systems (CDIS) also help to improve the accuracy of clinical documentation.