Discussions and articles about clinical documentation improvement (CDI) and accurate billing sometimes focus on the negative, revenue reductions when not providing accurate documentation or billing. Yet, there is a big upside that medical providers should also consider.
All agree that submitting accurate documentation for all patient events is critical to receive timely reimbursements and fulfilling reporting responsibilities. Healthcare reform has only increased the importance of accuracy for all documentation requirements.
Most, if not all medical providers are aware of the serious focus on CDI and all documentation accuracy as a component of the move from fee-for-service to pay-for-performance foundations. However, it is much more productive to target the positives of achieving accuracy than focusing on the downsides of submitting and recording poor documentation.
While ICD-10 coding implementation dominated center stage for months, the installation postponement does not really affect the criticality of CDI. Although this postponement gives providers a new window to provide ore thorough staff training and education, it does not affect meaningful use requirements, Centers for Medicare and Medicaid Services (CMS) regulations or private payer attention to accurate claims submissions.
Therefore, it behooves all medical providers to adopt best practice CDI initiatives. If you identify and focus on the opportunities, instead of the potential downsides, you create more positive possibilities to maintain or increase your revenue stream.
Estimates for 250-bed hospitals indicate they could increase annual revenue by around $2.5 million by having an effective CDI and billing program. While providers with private practices need to scale back that volume, a similar increased revenue percentage could result. It's obviously worth the effort to improve staff accuracy of documentation.
Best Practices for CDI and Billing Accuracy
- Prioritize CDI and billing improvement opportunities to those offering the largest ROI possibilities.
- Train staff effectively to achieve CDI.
- Become engaged and committed to documentation improvement.
- Make your staff accountable for accuracy, with reasonable goals and incentives.
- Retain a top third-party firm like M-Scribe to manage CDI and billing to improve accuracy.
These efforts will improve CDI and billing accuracy to keep your revenue strong and maintain compliance. An additional best practice that is critical to keeping revenue high and delivering quality care, is putting patient care first.
Providers or key staff should participate in valuable web-based or in-person conferences and seminars to capture the knowledge needed to improve documentation and billing accuracy. This approach helps you to meet regulatory requirements, while keeping reimbursement revenue consistent.
CDI is an issue you must address. It's not going away. You may find that improved documentation also delivers revenue opportunities you may have missed in the past. You will be happy if you identify prior missed income opportunities. Save your regret and take advantage of new or previously missed reimbursement and revenue increases now.
Suggestions to Enhance CDI Success
- Make CDI a priority to increase revenue.
- Ensure sufficient and trained staff.
- Install good tracking procedures or software.
- Establish accuracy accountability standards for your staff.
- Emphasize the benefits of compliance to staff.
- Stress the importance of accurate electronic medical records (EMRs).
There is no downside, only upside, to installing best-in-class DCI procedures. The time you spend creating policies and procedures that encourage documentation and billing accuracy only increase practice revenue.
Your time spent on designing these systems result in a return on investment (ROI) that will impress the best Wall Street Trading Gurus. Your patients will be happy, your practice manager will be pleased and you will benefit beyond your former expectations of projected revenue levels. You can discard concerns about wasting time or effort to achieve CDI.
Your priority for improving documentation and billing accuracy will deliver increased revenue, while keeping you and your medical practice in compliance with meaningful use and all reporting regulations. Your bank account will be pleased and you will sleep more soundly.