Clinical Documentation Improvement (CDI) Programs

PRG has years of experience in starting and leading successful pediatric CDI programs at children’s hospitals and pediatric units around the country. Accurate documentation of the patient’s care is important for the sharing of information amongst the clinical team to provide the best care possible. In addition, complete documentation also ensures that the appropriate acuity of the patient is reflected in the chart, which drives the severity-adjustment for quality and operational metrics and can also significantly impact hospital reimbursement.

Appropriately documented and coded diagnoses drive the severity-adjustment when looking at severity-adjusted length-of-stay, severity-adjusted complication rates, severity-adjusted mortality rates and other severity-adjusted metrics. When trending your own hospital’s performance over time or when comparing yourself to peer organizations, it’s critical that the appropriate coding and severity-adjustment is accounted for to ensure that the common phrase of “we have sicker patients” is truly reflected in the coding of the record.

This coding and severity-adjustment is also what drives hospital reimbursement in certain payment models. To ensure hospitals receive full and fair compensation for the care they provide to their patients, it’s important for the coding department to code at the appropriate acuity level.

“Coding language” and “clinical language” can be different for many of the conditions we care for. We don’t want physicians to be coders and to remember when to use certain code-able phrases. To bridge this gap between “code-able” and “clinical” language, hospitals rely on clinical documentation improvement (CDI) programs to ensure the chart is documented and coded correctly.