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 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. [1] 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. [1] 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. [2] 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. [1]
To remain competitive in the value-based care ecosystem, hospitals depend on the CDIS. To support reimbursements, payers rely on clinical documentation and precise coding. Additionally, a lack of information or assigning DRGs with a lower relative weight may cause hospitals to lose out on reimbursements and face value-based penalties. There have been cases where healthcare providers missed out on incentive payments due to a lack of achievement documentation to show payers.
Hospitals can prevent such mishaps by leveraging a skilled CDI team. According to a 2016 Black Book Market Research survey, almost 90% of hospitals that employed a strong CDI program with skilled specialists earned at least $1.5 million more through reimbursements and healthcare revenue. Most of the additional revenue came from improving key performance indicators (KPIs) such as the Case Mix Index (CMI) through CDI. [3]
Healthcare documentation serves as a legal document, validates the patient care provided, facilitates claims processing, coding, billing and reimbursement, and facilitates quality reviews. [4]
Diagnosis-related group (DRG) is a system to classify hospital cases into one of originally 467 groups, with the last group being "Ungroupable". This system of classification was developed as a collaborative project by Robert B Fetter, PhD, of the Yale School of Management, and John D. Thompson, MPH, of the Yale School of Public Health. The system is also referred to as "the DRGs", and its intent was to identify the "products" that a hospital provides. One example of a "product" is an appendectomy. The system was developed in anticipation of convincing Congress to use it for reimbursement, to replace "cost based" reimbursement that had been used up to that point. DRGs are assigned by a "grouper" program based on ICD diagnoses, procedures, age, sex, discharge status, and the presence of complications or comorbidities. DRGs have been used in the US since 1982 to determine how much Medicare pays the hospital for each "product", since patients within each category are clinically similar and are expected to use the same level of hospital resources. DRGs may be further grouped into Major Diagnostic Categories (MDCs). DRGs are also standard practice for establishing reimbursements for other Medicare related reimbursements such as to home healthcare providers.
Case mix, also casemix and patient mix, is a term used within healthcare as a synonym for cohort; essentially, a case mix groups statistically related patients. An example case mix might be male patients under the age of 50, who present with a myocardial infarction and also undergo emergency coronary artery bypass surgery.
The Health Insurance Portability and Accountability Act of 1996 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, 1996. It modernized the flow of healthcare information, stipulates how personally identifiable information maintained by the healthcare and healthcare insurance industries should be protected from fraud and theft, and addressed some limitations on healthcare insurance coverage. It generally prohibits healthcare providers and healthcare businesses, called covered entities, from disclosing protected information to anyone other than a patient and the patient's authorized representatives without their consent. With limited exceptions, it does not restrict patients from receiving information about themselves. It does not prohibit patients from voluntarily sharing their health information however they choose, nor does it require confidentiality where a patient discloses medical information to family members, friends, or other individuals not a part of a covered entity.
Medical billing is a payment practice within the United States healthcare system. The process involves the systematic submission and processing of healthcare claims for reimbursement. Once the services are provided, the healthcare provider creates a detailed record of the patient's visit, including the diagnoses, procedures performed, and any medications prescribed. This information is translated into standardized codes using the appropriate coding system, such as ICD-10-CM or Current Procedural Terminology codes—this part of the process is known as medical coding. These coded records are submitted by medical billing to the health insurance company or the payer, along with the patient's demographic and insurance information. Most insurance companies use a similar process, whether they are private companies or government sponsored programs. The insurance company reviews the claim, verifying the medical necessity and coverage eligibility based on the patient's insurance plan. If the claim is approved, the insurance company processes the payment, either directly to the healthcare provider or as a reimbursement to the patient. The healthcare provider may need to following up on and appealing claims.
A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track diseases and other health conditions, inclusive of chronic diseases such as diabetes mellitus and heart disease, and infectious diseases such as norovirus, the flu, and athlete's foot. Procedure classifications list procedure code, which are used to capture interventional data. These diagnosis and procedure codes are used by health care providers, government health programs, private health insurance companies, workers' compensation carriers, software developers, and others for a variety of applications in medicine, public health and medical informatics, including:
The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization that accredits more than 22,000 US health care organizations and programs. The international branch accredits medical services from around the world.
In the healthcare industry, pay for performance (P4P), also known as "value-based purchasing", is a payment model that offers financial incentives to physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures. Clinical outcomes, such as longer survival, are difficult to measure, so pay for performance systems usually evaluate process quality and efficiency, such as measuring blood pressure, lowering blood pressure, or counseling patients to stop smoking. This model also penalizes health care providers for poor outcomes, medical errors, or increased costs. Integrated delivery systems where insurers and providers share in the cost are intended to help align incentives for value-based care.
A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). The NPI has replaced the Unique Physician Identification Number (UPIN) as the required identifier for Medicare services, and is used by other payers, including commercial healthcare insurers. The transition to the NPI was mandated as part of the Administrative Simplifications portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The AAPC, previously known by the full title of the American Academy of Professional Coders, is a professional association for people working in specific areas of administration within healthcare businesses in the United States. AAPC is one of a number of providers who offer services such as certification and training to medical coders, medical billers, auditors, compliance managers, and practice managers in the United States. As of April 2019, AAPC has over 190,000 worldwide members, of which nearly 155,000 are certified.
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 standardized codes using a classification system. The health data produced are an integral part of health information management, and are used by local and national governments, private healthcare organizations and international agencies for various purposes, including medical and health services research, epidemiological studies, health resource allocation, case mix management, public health programming, medical billing, and public education.
ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. Work on ICD-10 began in 1983, became endorsed by the Forty-third World Health Assembly in 1990, and was first used by member states in 1994. It was replaced by ICD-11 on January 1, 2022.
Health information technology (HIT) is health technology, particularly information technology, applied to health and health care. It supports health information management across computerized systems and the secure exchange of health information between consumers, providers, payers, and quality monitors. Based on a 2008 report on a small series of studies conducted at four sites that provide ambulatory care – three U.S. medical centers and one in the Netherlands, the use of electronic health records (EHRs) was viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system.
A rural health clinic (RHC) is a clinic located in a rural, medically under-served area in the United States that has a separate reimbursement structure from the standard medical office under the Medicare and Medicaid programs. RHCs were established by the Rural Health Clinic Services Act of 1977, . The RHC program increases access to health care in rural areas by
Bundled payment is the reimbursement of health care providers "on the basis of expected costs for clinically-defined episodes of care." It has been described as "a middle ground" between fee-for-service reimbursement and capitation, given that risk is shared between payer and provider. Bundled payments have been proposed in the health care reform debate in the United States as a strategy for reducing health care costs, especially during the Obama administration (2009–2016). Commercial payers have shown interest in bundled payments in order to reduce costs. In 2012, it was estimated that approximately one-third of the United States healthcare reimbursement used bundled methodology.
An accountable care organization (ACO) is a healthcare organization that ties provider reimbursements to quality metrics and reductions in the cost of care. ACOs in the United States are formed from a group of coordinated health-care practitioners. They use alternative payment models, normally, capitation. The organization is accountable to patients and third-party payers for the quality, appropriateness and efficiency of the health care provided. According to the Centers for Medicare and Medicaid Services, an ACO is "an organization of health care practitioners that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it".
The Expanding Medical and Behavioral Resources with Access to Care for Everyone (EMBRACE) plan is a healthcare system reform proposal introduced by a group called Healthcare Professionals for Healthcare Reform (HPfHR). The plan incorporates elements of private health insurance, single-payer and fee-for-service models in one comprehensive system. It has been referred to as a "Single System" healthcare system. First published in the Annals of Internal Medicine in April 2009, the plan got some early discussion in the healthcare community, but appeared to have come out too late to have had any impact in the development of the Patient Protection and Affordable Care Act (PPACA), the 111th Congress’ landmark health insurance reform legislation. A book outlining the EMBRACE plan in more detail was authored in 2016 by Dr. Gilead Lancaster, a cofounder of HPfHR.
Health care quality is a level of value provided by any health care resource, as determined by some measurement. As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. The goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure good quality of life, cure illnesses when possible, to extend life expectancy, and so on. Researchers use a variety of quality measures to attempt to determine health care quality, including counts of a therapy's reduction or lessening of diseases identified by medical diagnosis, a decrease in the number of risk factors which people have following preventive care, or a survey of health indicators in a population who are accessing certain kinds of care.
The Physician Quality Reporting System (PQRS), formerly known as the Physician Quality Reporting Initiative (PQRI), is a health care quality improvement incentive program initiated by the Centers for Medicare and Medicaid Services (CMS) in the United States in 2006. It is an example of a "pay for performance" program which rewards providers financially for reporting healthcare quality data to CMS. PQRS ended in 2016, beginning with the 2018 payment adjustment. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaced this and other CMS quality programs with a new umbrella program called the Quality Payment Program (QPP), under which clinicians formerly reporting under PQRS would instead report quality data under one of two QPP program tracks: the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Model (APMs) track.
Credentialing is the process of establishing the qualifications of licensed medical professionals and assessing their background and legitimacy.
A hospital readmission is an episode when a patient who had been discharged from a hospital is admitted again within a specified time interval. Readmission rates have increasingly been used as an outcome measure in health services research and as a quality benchmark for health systems. Generally, higher readmission rate indicates ineffectiveness of treatment during past hospitalizations. Hospital readmission rates were formally included in reimbursement decisions for the Centers for Medicare and Medicaid Services (CMS) as part of the Patient Protection and Affordable Care Act (ACA) of 2010, which penalizes health systems with higher than expected readmission rates through the Hospital Readmission Reduction Program. Since the inception of this penalty, there have been other programs that have been introduced, with the aim to decrease hospital readmission. The Community Based Care Transition Program, Independence At Home Demonstration Program, and Bundled Payments for Care Improvement Initiative are all examples of these programs. While many time frames have been used historically, the most common time frame is within 30 days of discharge, and this is what CMS uses.
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