Clinical documentation serves as a foundation for every patient’s health record. It facilitates “the accurate representation of a patient’s clinical status that translates into coded data.” With a properly implemented clinical documentation improvement (CDI) program, organizations can paint a picture for all team members involved in a patient’s care, boost healthcare revenue and reimbursements, and optimize high-value specialist utilization.

It’s essential that a patient’s severity of illness and clinical treatments are documented, and CDI experts embrace the task of putting sustainable solutions into action. This helps to improve the quality of care while also improving coding, billing, and compliance processes. The improvement of patient outcomes is vital to value-based care, and accurate billing and reimbursement serve to promote revenue for services, including virtual care. 

Let’s take a deeper look at what CDI experts bring to the table, including how they can help healthcare organizations to successfully maintain their telehealth initiatives.

Painting an accurate clinical picture

With the rise in value-based care reimbursement and the continued need to accurately document diagnoses and treatments, documentation quality is a key concern. The shift to value-based care has also created a concern for overall wellness and prevention. This is prompting providers to focus beyond traditional fee-for-service business models and take on greater risk of delivering outcomes. There are also gaps between clinical care and revenue integrity, and poor clinical documentation can be a primary cause. 

young nurse with patient

Much of the burden for clinical documentation is placed on physicians who spend hours documenting patient encounters for reimbursement. In addition to creating physician burnout, doctors may input information that is not sufficiently accurate for analysis. CDI experts can help complete accurate data to providers in a timely manner, a move that can reduce physician burnout while closing the gaps in clinical documentation, care delivery, and revenue integrity.  

Exploring the connection between CDI and telehealth 

The explosive growth of telehealth during the pandemic is undeniable, and the move to maintain and expand its availability post-pandemic is strategic and essential in our virtual age. Organizations recognize the value, flexibility, and convenience it provides to patients – particularly with the continued shift to value-based care in mind – and use it tackle goals such as:

  • attracting and retaining patients
  • increasing volume
  • reducing costs
  • supporting preventive care

CDI professionals are needed to help activate the work toward these goals. For telehealth to help organizations meet financial goals, reimbursements must be optimized. That requires up-to-date knowledge in ever-evolving regulations and requirements, including Medicare telehealth billing requirements. CDI teams collaborate with organizations to focus on “documentation improvement-related activities for risk capture during telehealth visits” as well as on data investments “to identify care gaps and revenue opportunities during telehealth encounters.”

CDI teams can also support financial departments in audits as they “analyze providers’ billing patterns for telehealth services.” The digital trail of services and treatments serves as evidence of care provided and accurately represents patient populations, a move that can ultimately improve population health outcomes. It also adds yet another layer of commitment to an organization’s navigation to value-based care. 

Key takeaways

  • Clinical documentation is the cornerstone of every patient’s medical record.
  • CDI experts are increasingly impactful to both the patient and your organization, including as telehealth continues to expand. 
  • The continued shift toward value-based care mean that now more than ever documentation must be accurate and updated.
  • Having a partner in human capital management to identify and deliver CDI professionals will allow your providers to focus on patients while relying on experts to streamline the documentation process. 

telehealth documentation

Having a partner consult with your organization about its CDI needs makes it easier to facilitate your approach to decreased denials, enhanced revenue, and improved quality of care. 

Harmony is primed to identify experts who are highly qualified to tackle goals such as:

  • securing a return on your organization’s investment
  • keeping pace with regulatory changes
  • decreasing denials to manage for optimal financial performance
  • maximize quality clinical outcomes
  • streamlining the CDI process for improved efficiencies and effectiveness
  • supporting capture of all diagnoses
  • maintaining compliance

If you’re a CDI expert and looking to grow your career, we have a team of recruiters to help you polish your resume, introduce you to clients, and negotiate the best offer that fits your lifestyle.

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