Clinical Documentation Improvement

Paving the Way for Regulatory Compliance

Clinical documentation improvement (CDI) has emerged as a strategic imperative for hospitals, physician practices and healthcare organizations seeking to improve compliance, quality and appropriate reimbursement. Insufficient documentation impacts nearly all aspects of clinical and business operations - from coding and billing to revenue recovery and even patient care.

Effective clinical documentation is the key to successfully navigating a number of significant healthcare initiatives - from the transition to ICD-10 to mitigating the financial implications of pre- and post-payment RAC and payer audits. The need for improvement is more important than ever.

Improving procedure documentation is an important subset of any CDI initiative. Procedure documentation improvement is uniquely challenging due to a high degree of clinical variability and complexity.

Insufficient procedure documentation can result in:

  • Delayed communications of results or patient information
  • Improper or unsubstantiated coding leading to inappropriate reimbursement levels and audit risks
  • Inaccurate or incomplete quality registry reporting

ProVation® MD Guides Procedure Documentation, Enhances CDI Initiatives

  • Quickly guides physicians through documentation processes and helps ensure no details are missed and all information has been thoroughly captured
  • Improves the clarity of procedure-related documentation in alignment with strategic quality initiatives, including Quality Registry, CMS/Payer Initiatives, Clinical Quality and Business Operations Analysis and Revenue Cycle Management
  • Produces more complete procedures notes, thus providing accurate documentation for audit-support purposes