What is Clinical Documentation Improvement?

A Clinical Documentation Improvement (CDI) program is designed to improve inpatient record documentation by establishing a coordinated, systemic process utilizing a concurrent review team to strengthen communication between caregivers, physicians and the coding professionals. This program ensures that the clinical documentation in the patient record accurately reflects the patient’s principal diagnosis (reason for admission) as well as the Secondary diagnoses (co-morbid conditions) and captures the procedures performed.

Why Clinical Documentation Improvement?

CDI empowers:

  • Improved Provider Documentation
      Completeness and specificity creates quality
  • Knowledge of clinical documentation requirements improves patient experience
      Clinical indicators for common inpatient diagnoses/comorbidities
      ICD-10-CM and ICD-10-PCS coding guidelines
      MS-DRG assignment and other reimbursement methodologies
      Present on Admission (POA) documentation for medical/surgical complications and other hospital-acquired conditions
  • Provider Education
      Providers and medical leadership regarding documentation guidelines and reporting presenting value of improvement
  • Revenue Enhancement
Acurus CDI Services
  • Acurus Personnel on site for up to 3 months
      Working in parallel with Acurus remote CDI specialists
      On site person responsible for documentation, doctor interaction, client training and transition to client CDI support person
  • Phased Approach
  • Data Analytics
      Bench mark between similar hospitals and calculate CMI on a monthly basis
      Monthly reports with line item detail presenting changes, original and post compensation
  • Improved Documentation, Patient Experience, Provider Education and Revenue