Clinical Document Improvement (CDI) Trends in Medical Coding

Interested in becoming a medical billing and coding specialist? An area that a medical billing and coding specialist must work with other medical professionals to improve accuracy is clinical documentation and medical coding. Both of these elements of a medical billing and coding specialist’s job are increasingly important to health care providers as they work hard to remain sustainable and competitive in the world of medicine.

But first, what is clinical documentation improvement? What are the problems plaguing clinical documentation? Finally, what are the advancements and technology that will help improve clinical documentation and medical coding accuracy.

What is Clinical Documentation Improvement (CDI)?

A program that helps to incorporate the terminology needed for a medical billing and coding specialist to accurately translate a patient’s condition into precise medical code. Through medical record review, the medical coding professional will capture important clinician documentation while the patient is in the medical facility.  The request is then sent to a clinician for clarification and additional documentation to assign the proper medical code.

Problems Plaguing Clinical Documentation

The first problem that affects clinical documentation accuracy is incomplete or inaccurate documentation. If the incorrect medical code is assigned to a patient’s treatment, diagnosis or procedure, the billing is incorrect. This may cause patients overbilling costs or the medical facility incorrect reimbursement. With the help of clinical documentation improvement, errors and mis-coding can be caught early which leads to higher quality care and accurate reimbursement.

The next problem for accurate clinical documentation is physician query fatigue. Precise medical coding places unnecessary demand on physician’s time. Giving the physician a central platform to input medical coding can improve query fatigue.

The final problem that affects the accuracy of clinical documentation is that medical coders, medical professionals and clinical documentation specialists may be located in different locations so collaboration may be difficult. A single platform reduces the amount of cross-input and errors that will occur with multiple platforms for medical coding and clinical documentation.

Without absolute accuracy in clinical documentation and medical coding, health care providers cannot receive the correct reimbursement, which can cause a negative impact on profitability and ultimately patient care. With this in mind, trends in medical coding queries and CDI will integrate mobile technology and offer solutions that aim to improve accuracy for better outcomes. These solutions will be for both physicians and hospitals. Here are a few trends to watch in 2018 and into 2019. They include advancements in new technology, improvements in value-based purchasing, physician support, and consumer access to data.

Advancements in CDI from New Technology

New developments in technology will continue to create innovations within the healthcare industry. Some of these innovations will be centered around the process of CDI physician queries. These queries are important to keeping accurate documentation of care. The improvements will simplify the query process. At the same time, they will significantly decrease the time medical billing and coding specialists spend on follow ups with physicians to double-check query answers. Hospitals without an adequate number of CDI specialists stand to benefit a lot from this trend. As medical billing and coding specialists spend less time on query follow-ups, their overall productivity will increase.

Value-Based Purchasing Will Become More Efficient

Medicare has instituted the Medicare Hospital Value-Based Purchasing Program, which aims to promote greater efficiency in hospitals by basing payments on the quality of care provided to patients. The program adjusts payments to healthcare providers through the CMS Inpatient Prospective Payment System.

This reimbursement program makes it absolutely critical for hospitals to continually improve coding accuracy. This will help ensure that physician documentation results in proper payments from Medicare.

Physician Support Will Improve with CDI

It is no secret that physicians report a high level of burnout. The most recent surveys show that more than half of doctors report having recurring or continuing feelings of burnout.

Because of this alarming trend, the healthcare industry is working hard to address physician burnout. In fact, the Stanford University School of Medicine joined with the Rochester, Minnesota based Mayo Clinic and the American Medical Association to present the American Conference on Physician Health. The innovative conference focused on methods that industry organizations can adopt to help lessen physician burnout and increase physician well-being.

What does medical coding and CDI have to do with this? Advancements in technology will help healthcare providers complete coding queries with greater speed and efficiency. Physicians are demanding better solutions. Technology will answer those demands with programs that make that aspect of their jobs easier rather than harder.

Greater Consumer Access to Data on Quality of Care with CDI

Big data is creating an industry in which healthcare consumers can research provider quality scores with ease from a variety of reporting sources, such as Leapfrog and Healthgrades.

Because these scoring services utilize a provider’s coded data, any inaccuracies in medical coding can result in lower rankings. Providers will become more concerned of this relationship between medical coding and consumer awareness. Physicians and hospitals will work to ensure their public reputation is protected and their quality of service is properly reflected.

Accurate medical coding and CDI are foundational to improvements in many areas of healthcare. The overall industry, physicians, and patients all rely on data for better decision-making and outcomes. These trends will drive progress and enhancements in medical coding.

Did learning clinical document improvement trends interest you in becoming a medical billing and coding specialist? Gwinnett Colleges & Institute’s Medical Billing and Coding programs will provide you with the opportunity to learn insurance coding and processing, medical administrative procedures, and the regulatory requirements in the healthcare delivery system.  School externships provide the opportunity to apply the medical billing and coding skills learned in the classroom in actual medical settings. Gwinnett Colleges & Institute offers medical billing & coding courses to gain essential skills and training to achieve entry-level positions in this career field. These medical billing & coding courses will be the first step in starting a rewarding career.

Contact us to learn more about how you can become a medical billing and coding assistant today.