ACDIS/AHIMA compliant clinical documentation integrity technology standards

Clinical documentation is the cornerstone of medical data and the foundation of patient care. It provides a lasting record of the patient’s history, diagnoses, tests, and treatments. An accurate and complete health record is beneficial not only to ensure that the severity and risk of illness of the patient is accurately reflected, but it also benefits the patient-provider relationship and aids in population health management and research. Health record documentation is translated into diagnostic and procedure codes that can be used for data mining (for example, by the Centers for Medicare and Medicaid Services or payers) to support improvements in patient care.

In addition, accurate clinical documentation and subsequent coding can help ensure appropriate reimbursement and reporting of quality metrics under value-based purchasing methodologies. Providers are the subject matter experts in clinically diagnosing and creating an appropriate treatment plan for their patients. Clinical documentation integrity (CDI) professionals are the translators and validators of the health record, working to ensure complete and accurate information. Health information and coding professionals translate documentation in health record into reportable codes. In an effort to achieve coding accuracy, which impacts quality and reimbursement, CDI and coding professionals use tools within the electronic health record (EHR) to assist in coding and ensure that any potential documentation opportunities are queried for clarification.

The advancement of technology has opened the door to streamline CDI initiatives, and when implemented effectively, it can reduce the administrative burden on providers and achieve high-quality documentation. CDI professionals often work in partnership with technology products and vendors to improve clinical documentation. This white paper seeks to ensure that, as we incorporate more novel and sophisticated technologies, we do so in a systematic and judicious manner.

In this white paper we offer:

• Information on the variety of technology solutions currently available
• Strategies to assess their compliance with CDI and coding practice guidelines
• Methods for creating synergy between CDI and coding departments and novel technology solutions