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CDI - Clinical Documentation Intelligence

By: AE & Associates CDI
  • Summary

  • Clinical documentation improvement (CDI) is the process of reviewing medical record documentation for completeness and accuracy. CDI includes a review of disease process, diagnostic findings, and what the documentation might be missing. A CDI specialist often has both clinical and medical coding backgrounds. Bridging the gap between clinical documentation and accurate coding drives CDI programs. AE & Associates offers CDI Education and Training as well as Clinical Coding Assessment, Observation Rate Review & Analysis, Chargemaster Reviews and Denial/Appeal Assessment & Modernization. Find us at http://cdi.care
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Episodes
  • CDI Intelligence - A Physician’s Perspective - Kyle Boyd (RN, CCDS)
    Mar 28 2023

    Join Kyle Boyd, RN, CCDs on The Clinical Documentation Intelligence Podcast, aka a podcast for "The CDI", where Kyle shares his passion and thoughts on how CDI can work together to change the "Clinical Revenue Cycle for the Better." The revenue cycle is siloed with each component of the revenue cycle not communicating and working towards the common goal of quality focused patient centered fully informed coordinated care supporting an optimally performing revenue cycle. Kyle discusses the role of CDI in breaking down silos, serving as the torch bearer and change agent for jumping start a more highly efficient revenue cycle, thinking outside the box when it comes to transforming CDI to a more proactive approach to improving physician documentation. CDI specialists are handicapped to some extent in broadening their breadth and depth of contribution to achieving sustainable true measurable meaningful improvement in physician documentation, attributable to the traditional CDI KPIs that do not actually correlate with real physician documentation integrity. Kyle provides his ideas on how the CDI profession can convince and make a compelling case for CFOs and other Revenue Cycle professionals to expand their knowledge and understanding of CDI, allowing the profession the latitude and direction to branch out, reinvigorate and reinvent CDI processes to drive real documentation integrity beyond the current narrow scope of CDI as it exists today. Current CDI efforts have not produced real change in physician documentation patterns due to constraints beyond our control and expectations that narrowly define our present chart review process.

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    26 mins
  • CDI Clinical Documentation Intelligence - A physician’s perspective - Mark Johnson PAC(MPAS)
    Mar 11 2023

    Mark Johnson PAC (MPAS), a Physician Assistant with almost two decades of experience, is the featured guest on the Clinical Documentation Intelligence Podcast today. He is passionate about provider documentation and discusses the common documentation challenges faced by all medical practitioners. One of the major causes of burnout among providers is the electronic health record, which demands that providers spend at least two hours away from patient care to document in the EHR. Mark shares his strategies for streamlining his documentation process, reducing the time he spends working on the computer, and dedicating more time to caring for patients. He also offers his insights into what providers expect from the Clinical Documentation Integrity profession, including practical educational training on how to improve documentation, the importance of working smarter, not harder, while charting in the EHR, and the need for regular constructive feedback, rather than additional queries, to enhance their documentation skills.

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    40 mins

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