Clinical Documentation Improvement Essay

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Recommended: Overview of clinical documentation improvement

Clinical documentation improvement (CDI) is the process of reviewing the clinical documents by specialists to response to concerns regarding coding issues, quality and care management of patients’ services. According to Oach and Watter, hospitals invest in CDI programs to guarantee the contents of electronic health records (EHR) indicate actual conditions of their patients. CDI assists in reducing chances of unclear and incomplete documents, which may lead to losing hospitals’ revenues. CDI promotes the accuracy of documentations, which results in correctly coded and billed to insurances to decrease rejection rates, increase payments compliance, and improve quality of report for researches of public health data and diseases’ trends. CDI is …show more content…

Coders need to adhere closely to compliance issues. Therefore, the process of hiring coders cannot be taken lightly. The qualification of coders depends on the organizations’ needs. For example, providers’ offices coders need to have knowledge of outpatient coding; inpatient facilities will not need coders with experience of primary cares. Additionally, coders must be familiar with insurances’ policies, such as commercial insurances, Medicare, and Medicaid. Coders need to have efficient understanding of coding systems, such as: ICD-9, ICD-10, CPT, and HCPCS (Healthcare Common Procedure Coding System) codes. Although experiences are matter, educations should be considered when hiring new coders. Skills and experiences come with time; well-educated backgrounds could prepare coders for learning and adjusting to new coding information easier. A good method to find qualified coders at interviews is testing their knowledge via a small quiz. The quiz should be related to most common situations that occur in the facility. Additionally, it should include coding and medical terminologies questions. Based on the results, the hiring personnel can find good candidates (Israel,

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