Clinical Documentation Improvement

Inpatient

The CDI FOCUS program developed by Administrative Consultant Service takes the complexities of reimbursement methodologies and risk-adjusted quality measures and narrows the focus to allow your staff to concentrate on key indicators for coding accuracy and documentation adequacy. ACS does not have a "one size fits all" approach to CDI.  The objective should be to establish a documentation improvement process that functions collaboratively with documentation improvement professionals, physicians and coders.  Our consultative approach includes the following steps:

  • Organizational assessment: Extensive data analysis, record review and process analysis to identify hospital-specific needs for documentation improvement, staffing and process improvement;
  • CDI Focus education for CDI staff, coders and medical staff with initial classroom style training and case studies, supported by elearning lessons for review and re-education;
  • Side-by-side training with CDI specialists;
  • Development of a CDI leadership team to assure ongoing monitoring and program effectiveness;
  • Periodic reassessment of data, coding accuracy and documentation adequacy with adjustment of CDI goals as the program matures. 

Outpatient

The hospital outpatient setting is a rapidly growing area with more procedures, surgeries and tests performed in that arena everyday.  Successful outpatient CDI models are designed based on facility priorities for improvement of their most vulnerable areas.  ACS understands these trends and the rising need for organizations to establish on effective outpatient CDI program. Hospitals and providers should strive for complete, compliant documentation no matter the patient's location. The ACS Outpatient CDI program is designed specifically to improve coding and documentation for:

  • Emergency Department
  • Outpatient Surgery
  • Observation Services
  • Hospital Outpatient Ancillary Services

Let ACS help your organization implement an outpatient CDI program by providing an initial review to identify problem focused areas causing denials, non-covered charges and inaccurate assignment of evaluation and management levels due to inadequate documentation.  

Ambulatory 

Ambulatory freestanding and provider-based clinic encounters can benefit from outpatient CDI efforts.  Due to the level of specificity required in ICD-10-CM there will always be opportunities to improve provider documentation across all types of ambulatory clinics.  CDI specialists can identify opportunities for documentation specificity and educate providers on how to appropriately and compliantly document the severity of illness and health status of their patients.  An ambulatory CDI program can support payment accuracy while improving data integrity and risk adjustment under a wide variety of programs and payment models.