Clinical Documentation Improvement

Develop a precise picture of patient care to improve clinical and quality standards – and your revenue cycle.

Supporting exceptional patient care with high-quality clinical documentation has never been more important. As healthcare shifts from fee-for-service to value-based payment strategies, performance-based monetary incentives and penalties affect both providers and healthcare organizations. Clinical documentation serves to accurately capture the events of each patient encounter and properly reflect the services provided – enhancing patient care delivery and the healthcare revenue cycle.

EXTEND’s Clinical Documentation Improvement (CDI) services facilitate accurate, complete, up-to-date clinical documentation. Our experienced, credentialed CDI specialists meet strict quality assurance requirements and performance goals that measure both productivity and accuracy.

Quality Assurance: EXTEND Excellence

EXTEND’s CDI services are guided by a comprehensive set of standards, policies, procedures, and key performance metrics. These guidelines set forth requirements for productivity, provider engagement, program quality, and program compliance for our team members. Our program is fully monitored and evaluated to meet or exceed 95% accuracy, with retrospective reviews conducted on a regular basis and concurrent reviews when appropriate. Quality assurance monitoring process includes:

  • Appropriate timing and frequency of reviews
  • Accuracy of working DRG
  • Query indicators: Writing compliance, clinically viable/other multiple-choice options, response timing, and follow-up timing.
  • Missed query opportunities
  • Accuracy and quality of data collection

Supplemental CDI Resources for RCM Vendors

Revenue cycle services vendors who are looking to establish or expand their CDI team can also leverage EXTEND’s CDI knowledge and talent. Working together to supplement existing staff, we can provide experienced program managers, quality assurance personnel, and inpatient and outpatient CDI talent to meet the needs of healthcare organization clients:

  • Review charts and address CDI challenges,
  • Manage clinician queries,
  • Improve CDI workflow,
  • Support overnight and weekend CDI resource needs, and
  • Reduce the risk of CDI backlogs.

CDI Resources for Healthcare Organizations

Our domestic and global Clinical Documentation Improvement Specialists (CDIS) enable hospitals and outpatient facilities to extend their inpatient and outpatient CDI programs beyond the traditional 9 to 5 work hours, providing case review and queries when you need it most: after traditional domestic coder work hours and overnight. We work closely with clinicians to review records, identify missing or unclear information, and recommend documentation improvements that support complete, accurate records that match care delivery. Up-to-date, comprehensive clinical documentation can provide downstream benefits in the healthcare revenue cycle, such as:

  • Achieve accurate quality scoring and reporting,
  • Avoid poor audit findings by Medicare Recovery Audit Contractors (RAC) or other payers,
  • Maintain compliance with billing and coding regulations,
  • Generate more accurate code assignments, which leads to fewer claims denials, and
  • Maintain positive scores with grading agencies and government entities that evaluate hospitals for the public.

Financial and other results may vary depending on provider-specific circumstances, market position, and network affiliations.

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