Clinical Documentation Improvement (CDI)

Efficient & Accurate Clinical Documentation Improvement (CDI)

Discover how our CDI services can revolutionize your documentation process and elevate patient care. With a focus on accuracy, efficiency, and comprehensive clinical insights, our solutions empower healthcare providers to navigate complex documentation requirements seamlessly. Let us partner with you to unlock the full potential of your clinical documentation, driving better outcomes for both your patients and your organization.” Explore our CDI services now to see the difference firsthand

Introduction of Our CDI Service!​

In the complex landscape of healthcare delivery, accurate and comprehensive clinical documentation is paramount. Clinical Documentation Improvement (CDI) services have emerged as a cornerstone in ensuring that healthcare organizations maintain precise, thorough, and compliant documentation of patient care encounters. Backbone Data Solutions stands at the forefront, providing innovative technology solutions and expert support to elevate CDI processes to new heights of efficiency and effectiveness.

At Backbone Data Solutions experienced CDI assessment experts review provider documentation for accurate representation of patient’s clinical status. Medical records with inconsistent, deficient, or unspecified documentation can be damaging to the health of a patient and lead to a loss in revenue. A comprehensive analysis of clinical notes, diagnostic exams, lab results, and prescriptions is an essential step for a compliant and complete revenue cycle. Utilize our services to ensure that the complexity and severity of every patient encounter is appropriately captured for maximum reimbursement. Continual Clinical Documentation Improvement is fundamental to high-quality patient care and correct reimbursement. Backbone Data Solutions offers CDI solutions to ensure your patient’s record is accurate, complete, and has greater specificity of diagnostic and procedural documentation for optimal reimbursement. Our professional experts are continuously trained and educated to complement your team in various settings and operational circumstances. We pride ourselves in delivering high-quality CDI solutions and helping our clients achieve and exceed their operational and strategic goals. Learn more about our revenue cycle management solutions, explore Backbone Data Solutions medical coding solutions, medical billing solutions, HCC coding solutions, and ICD-10 third-party auditing solutions.

Purpose of a Clinical Documentation Improvement Program

A clinical documentation improvement program is a process designed and implemented with the purpose of achieving accurate and thorough medical record documentation.

Why are CDI programs needed? In many ways, the use of electronic health record (EHR) systems has eased the burden on providers and hospitals of navigating the administrative duties surrounding patient care and claim submission. However, the responsibility of medical record documentation — the entry of clinical information concerning care rendered to a patient — will always remain with the medical provider. To help providers succeed in this task, a CDI specialist is responsible for reviewing a patient’s medical record to ensure documentation reflects the specificity of current conditions to allow for accurate coding of the patient’s health status.

Impact and Purpose of a Benefits of CDI Program in the Inpatient Setting

CDI can improve the accuracy of coding and billing for inpatient facilities, which will result in more accurate reimbursement. The financial impact of an inpatient CDI program is not limited to initial payment of claims, though. Improper claim submissions resulting from poor documentation can result in unfavorable audits, which could require facilities to pay a fine, return money erroneously collected from payers, or both. Consequently, the role of CDI in claims processing in healthcare facilities includes both increasing the accuracy of initial reimbursement and preventing expensive consequences from reviews by authorities.

Hospitals are familiar with and subject to various types of audits. To guarantee their facility’s documentation withstands auditor scrutiny, a CDI specialist needs to be knowledgeable about the federal regulations regarding fraud, abuse, and compliance, as well as payer requirements for clinical presentations of diseases. For instance, the department of Health and Human Services (HHS) tasks the Office of Inspector General (OIG) with identifying, by way of the OIG’s Work Plan, incidences of fraud, waste, and abuse within medical claims submitted to the federal government. In one example of poor documentation practices in healthcare facilities — and documentation not supporting coding — an OIG audit was released in July 2020 that determined hospitals overbilled Medicare $1 billion by incorrectly assigning severe malnutrition diagnosis codes to inpatient hospital claims. In 200 claims reviewed in this audit, 164 contained severe malnutrition diagnosis codes when they should have had other forms of malnutrition or no malnutrition diagnosis codes at all. OIG recommended that Medicare collect the overpayments from providers where possible. A CDI specialist can help stop this sort of improper reporting and confirm patients have accurate diagnoses in the medical record by reviewing documentation and training providers and coders on the documentation required to support malnutrition diagnoses and codes. Program in the Inpatient Setting.

How CDI Can Help Maximize Revenue

Preventing unsupported diagnoses from being reported on a claim is one benefit of inpatient CDI programs. But ensuring all conditions that are clinically supported get reported is equally important because of how inpatient facility reimbursement works. To fully grasp how a CDI program can be successful for an inpatient facility from a financial perspective, it is necessary to understand Medicare’s DRG payment system. Many non-Medicare payers use an adaptation of this DRG payment system, as well.

Diagnosis related groups (DRGs) are just that: groupings of a patient’s diagnoses that are related and impact care during an inpatient stay. The patient’s principal diagnosis and up to 24 secondary diagnoses, including comorbid conditions (CC) or major comorbid conditions (MCC), determine the DRG assignment. The scenario below demonstrates the connection between diagnoses, DRGs, and reimbursement.

How CDI Can Improve Patient Care

In addition to the financial impact of an inpatient CDI program, the benefit to the overall well-being of the patient is significant as well. Poor records can impact patient care in a healthcare facility by affecting continuity and quality of care. The concurrent review of documentation by the CDI specialist enhances communication between all providers involved in the patient’s care in a timely manner, which may reduce the length of stay for the patient.

Similarly, a CDI program can help reduce avoidable readmissions by improving communication and care
coordination between patients and their caregivers at the time of discharge. Payers have taken note of these benefits and created programs to promote them. For instance, the Hospital Readmissions Reduction Program (HRRP) is a value-based purchasing program that reduces payment to hospitals with excess readmissions. In conjunction with HRRP, CMS assesses a broad set of healthcare activities that affect patients’ well-being.


Why Choose Us For CDI?

Backbone Data Solutions is a leading provider of clinical documentation improvement solutions and can help you conduct a complete assessment of your clinical documentation processes to identify any medical coding and process errors. Some other reasons to work with us include… 

We are a leading clinical documentation improvement services providing company and provide our services at highly affordable rates

We are ISO/IEC 27001:2022-certified and fully HIPAA-compliant, which ensures that we take stringent measures to protect your data from unauthorized use

We incorporate the latest clinical documentation improvement best practices and technologies, ensuring that you get the most accurate and up-to-date information

Our ISO 9001:2015 certification ensures that you will always receive near 100% accurate results when you outsource clinical documentation improvement services to us

Our ISO 9001:2015 certification ensures that you will always receive near 100% accurate results when you outsource clinical documentation improvement services to us

We are a highly dependable and responsible clinical documentation improvement firm and will always provide our services ahead of schedule and within budget

We provide only highly experienced and trained clinical documentation improvement professionals to our clients

Backbone Data Solutions offers state-of-the-art Electronic Health Record (EHR) systems and CDI software platforms tailored to the unique needs of healthcare organizations. These platforms streamline documentation workflows, making it easier for clinicians to capture relevant information accurately

We are ISO/IEC 27001:2022-certified and fully HIPAA-compliant, which ensures that we take stringent measures to protect your data from unauthorized use

Recognizing that every healthcare organization is unique, Backbone Data Solutions provides tailored consulting services to support the implementation and optimization of CDI programs. Their team of experts offers guidance on best practices, workflow optimization, staff
training, and performance measurement

Backbone Data Solutions is committed to providing end-to-end support throughout the CDI journey. From initial program design to ongoing maintenance and refinement, their dedicated team collaborates closely with clients to ensure the success of their CDI initiatives.

By improving documentation accuracy and completeness, Backbone Data Solutions CDI services drive revenue optimization for healthcare organizations, ensuring that they capture the full value of services provided

Through better documentation practices, clinicians can access a more comprehensive view of patient histories, leading to more informed decision-making and ultimately, better clinical outcomes

Backbone Data Solutions’ commitment to compliance ensures that healthcare organizations remain aligned with coding and documentation standards, mitigating the risk of audits and compliance-related penalties

By streamlining documentation workflows and leveraging technology-driven solutions, Backbone Data Solutions empowers healthcare organizations to operate more efficiently, freeing up valuable time and resources for patient care delivery.

Whether you are a hospital, clinic, or healthcare system seeking to enhance clinical documentation practices, optimize reimbursement, or mitigate compliance risks, Backbone Data Solutions is here to support you every step of the way. Contact us today to learn more about our comprehensive CDI solutions and discover how we can help you unlock the full potential of your clinical documentation processes.

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