Clinical Documentation Improvement Services

Clinical Documentation Improvement Services

Your health system’s clinical documentation must possess clarity, consistency, completeness, reliability, legibility, precision, and timeliness. Effective clinical documentation not only enhances the quality of care but also facilitates improved communication and reduces claim denials. However, achieving all these aspects simultaneously might appear challenging when your care team encounters frustration with the documentation process.

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Each hospital and health system possesses distinct needs, and at FirstVertex, we recognize and cater to this uniqueness. Elevate your existing CDI program with our adaptable and customized Clinical Documentation Integrity (CDI) services led by highly skilled and dedicated medical professionals. Our proficient team is well-versed in reviewing medical documentation, notifying physicians of inaccuracies, and enhancing overall CDI effectiveness. FirstVertex’s CDI services not only enhance performance and return on investment (ROI) but also offer a range of additional benefits:

  • Onsite or offsite services
  • Global or domestic solutions
  • Flexible staffing models
  • Improved ROI
  • Maximization of Diagnosis-Related Group (DRG)
  • Enhanced ICD-10 code assignment
  • Increased physician communication
  • Improved clinical performance

WHY OPT FOR FIRSTVERTEX’S ENHANCED CDI PROGRAM?

Choosing to outsource a segment of your business is a significant decision, especially when it impacts clinical outcomes and physician processes. Ultimately, the decision-making process revolves around what is best for you, your staff, your patients, and the community you serve.

FLEXIBILITY IN STAFFING:
Every collaboration initiates with an onsite component to acquaint our team with your existing clinical documentation practices. This approach offers numerous cost-effective options for your organization. Whether you prefer a fully onsite, offsite, global, domestic, or a hybrid CDI program, you have the flexibility to choose what aligns best with your organizational needs.

INCREASED COMMUNICATION
One of the trickiest parts of CDI is making sure everyone complies with a set of best practices and takes the necessary time to fully document an encounter. Communication is the key to ensuring all those involved are on the same page and expectations are clearly defined. The right communication pattern for your organization can help keep CDI top of mind and everyone working toward a common goal of improved documentation.

IMPROVE ROI: Enhancing clinical documentation has a ripple effect on various factors that directly influence ROI. A carefully crafted communication strategy contributes to improved performance and clinical outcomes. Thorough and accurate documentation ensures that your organization receives proper compensation for the services rendered. Improved documentation further streamlines coding efforts, reducing errors and the time coders spend deciphering complex documentation. This optimization ultimately leads to improved efficiency and financial returns for your organization.

CDI VS CODING:
A CDI specialist’s role revolves around ensuring the completeness and accuracy of physicians’ documentation regarding a patient. They may assist physicians in determining the patient’s Diagnosis-Related Group (DRG), though the final decision rests with the physician. On the other hand, a coder translates the documented information into assigned codes. While coders can identify errors in documentation, the presence of a CDI program tends to reduce such occurrences.

HOW CDI HELPS YOUR COMMUNITY:
Supplying high-quality data to the CDC and other government agencies enhances the likelihood of securing grants and funding. Moreover, accurate clinical documentation influences care decisions for a patient, both during their current stay and in the future. Ensuring precise documentation can significantly improve clinical outcomes and contribute to better overall patient care.

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