Future of Clinical Documentation: How It Helps in Maximizing the Revenues for The Hospital Sector?

When it is all about the financial health of your revenue management cycle and practice, clinical documentation might not be a compelling topic to care about. But when it comes to optimal patient care, it is the heart of practices for generating revenues from registered payers.

However, clinical documentation does not limit itself just to medical practices. Whether you are a coder, provider, administrator, or payer, documentation – either clinical or non-clinical is mandatory to have a smooth transition of financial and non-financial data. Timely and regular management of documentation helps in on-time reimbursements, positive patient outcomes, and steady compliance. With this wide range of benefits, it is crucial to understand and take notes on the essentialism of clinical documentation.

Nitty-gritty of clinical documentation

When a patient consults a provider in a hospital or privately, the information that is taken out at both levels of healthcare facilities in the form of documents is called clinical documentation. Through clinical documentation, the medical staff ensures that all the information about the patient is correct and accurate which plays an important role in the health and safety of a patient. Also, clinical documentation is required whenever a treatment or procedure is planned while the aim is to provide the best possible medical care. Besides, some other benefits may include reduced risks of claim denials and facilitating apt payer reimbursements.

Nitty-gritty of clinical documentation

What is CDI – Clinical documentation Integrity?

CDI – Clinical documentation integrity is also called clinical documentation improvement. It is designed to maintain accuracy, completeness, and consistency in order to improve the quality of patient data in the form of medical health records so the reimbursement claims would be made error-free.

According to The American Health Information Management Association (AHIMA);

“Successful clinical documentation integrity programs facilitate the accurate representation of a patient’s clinical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, disease tracking and trending, and medical research.”

All in all, clinical documentation is important for a smooth process at every level in the healthcare industry. This is because CDI keeps documentation on high priority. For this, the staff and the providers are needed to be trained and updated regarding the interventions of new releases and guidelines.

How does CDI work?

As far as CDI is concerned, it includes the disease process reviews, findings and analysis, diagnostics, and determining the missing documentation. However, a CDI officer having both medical and clinical coding background often finds the gaps and loops while compiling the documentation and medical coding essential for claim reimbursements.

In addition, CDI refers to all the documented entries by clinical and medical staff members and everyone at the medical facility who is responsible to provide medical care during every patient’s in-person visits.

CDI programs, however, have long been introduced and implemented in the health and medical industry but came to light in 2007 when the Centers for Medicare and Medicaid Services (CMS) announced Medicare Severity Diagnosis Related Groups (MS-DRGs). It is one of the authentic and recognized payment gateway systems that is used for reimbursements from payers under Medicare’s Inpatient Prospective Payment System (IPPS). While experiencing delays in payments and negative revenue sheets, hospitals are now realizing that obtaining an increased reimbursement rate and decreased compliance risks can only be possible if thorough and accurate diagnosis coding is used.

This leads to maintaining and arranging CDI programs where trained nurses review submitted clinical documentation for the inpatients’ medical treatment and analyze them concerning relevant ambiguities or incomplete information required for claim submission. This continuous practice enables increased reimbursement rates due to accurate billing at medical facilities.

How does CDI work

However, CDI programs have begun to take part in an inpatient hospital environment but the benefits of programs are there for outpatient as well. Although the process for inpatient and outpatient CDI programs may differ, they all share a similar goal of increasing coding and documentation accuracy on every level.

How can CDI help in maximizing revenue?

CDI programs help in generating revenue in many ways, whereas preventing unsupported codes and diagnoses from reporting in reimbursement claims is one of the benefits. On the same side, submitting the documentation and reporting the conditions that are clinically required and proven are equally important.

To understand the importance of CDI programs and how they work successfully from a financial perspective for an inpatient facility, understanding Medicare’s DRG payment system is mandatory.


The setting of inpatient and outpatient does not matter when the success of CDI programs is all you want. It solely depends on a healthcare provider. This is why trained and qualified professionals are only required to review CDI programs. For this, CDI-trained nurses with a sound experience in coding are some preferable candidates that facilities should look for when accurate billing and coding submission is required.