STAR Medical Auditing Services

Clinical Documentation Improvement

Clinical Documentation Improvement

successful clinical documentation practices ensure best quality patient care and timely reimbursement.

Today's health organizations recognize that proper clinical documentation is critical to their operations. Successful practices accurately reflect the care that was provided and the status of each patient, which in turn streamline and maximize reimbursement. A great Clinical Documentation Improvement (CDI) Consultant can help you navigate and elevate your documentation practices to the next level. 

STAR's CDI Experts are fully-credentialed Nurses that are also Certified Professional Coders. They can guide and educate providers to improve their documentation efforts, and act as the liaison between the providers and the coding team. They understand the intricate balance between clear and concise documentation and clinical evidence. Furthermore, they have deep knowledge of ICD-10 and CPT code assignments that not only meet medical necessity, but also are the highest specificity and correct sequence.


Star's 5-step to clinical documentation success

1. Assess documentation for coding readiness.  Focused documentation audits by specialty are critical to determining patterns of missing information that may impact coding and reimbursement under ICD-10 and CPT.  By understanding the clinical areas impacted most by vague or unclear documentation, your organization can tailor clinician education and improve documentation processes where needed.

2. Analyze the impact on claims.  Do you know how missed coding opportunities in ICD-10 and CPT will impact reimbursement?  If clinical documentation is incomplete, coding will be inaccurate and claims will be impacted.  Concentrate initial improvement efforts on those providers and/or service lines that offer the greatest opportunity or risk in terms of revenue impact.

3. Implement progressive clinician education. There has always been a disconnect between the language clinicians use to document care and the language coders need in order to code from the documentation.  Recent CMS guidelines prevent coders from questioning diagnoses or suggesting intended diagnoses to providers.  If it isn’t documented, it can’t be coded.  Progressive education allows medical staff to adjust documentation practices which in turn allows the coders to accurately report the diagnoses and procedures performed.

4. Establish a concurrent documentation review program.  When a CDI Expert can review documentation and query clinicians about inconsistencies before the patient is discharged, the complete clinical status, including secondary diagnoses and complications, can be captured.  Many organizations are finding it essential to implement concurrent review programs.

5. Streamline clinical documentation workflow.  By having a monthly random sampling of accounts selected for CDI audit that focuses on integration of documentation within clinical workflow, STAR CDI Experts can uncover trends in missing or vague documentation which leads to inaccurate coding.  These CDI audits provide clinically driven concepts and alert the STAR CDI Experts to query clinicians for additional information, saving time and improving efficiency when the accounts are received by the coders.