By Ricardo Mazzi and Gerry Petratos, MD
In today’s healthcare landscape, ensuring accurate clinical documentation is vital for delivering high-quality patient care and optimizing financial reimbursement. One effective strategy to achieve this is through the implementation of concurrent CDI audits. This blog post will explore the concept of concurrent CDI audits, shed light on the challenges faced by CDI audit teams, highlight the value of these audits, and showcase how HITEKS can empower healthcare organizations in streamlining their concurrent CDI audit processes.
What is a Concurrent CDI Audit?
Concurrent CDI audits involve the systematic and real-time evaluation of clinical documentation throughout a patient’s hospital stay. Unlike retrospective audits conducted after discharge, concurrent audits allow CDI specialists to identify and address documentation gaps promptly, ensuring more accurate and complete records.
Current CDI Audit Team Challenges
CDI audit teams often face various challenges that can impact their effectiveness. Some of these challenges include:
- Multiple competing priorities that divert their attention away from conducting thorough chart audits.
- Limited resources and staffing constraints, leading to delays and backlogs in the audit process.
- Dependence on data management for case lists, resulting in inefficiencies and delays in obtaining essential information for audits.
The Value of Concurrent CDI Audits
Implementing concurrent CDI audits brings several significant benefits to healthcare organizations, including:
1. Timely feedback
Real-time audits allow for immediate identification and resolution of documentation gaps, leading to accurate and comprehensive clinical records.
2. Enhanced compliance:
Concurrent audits enable proactive identification and rectification of compliance issues, ensuring adherence to regulatory guidelines and reducing the risk of denials and penalties.
3. Improved revenue integrity
By capturing and documenting diagnoses and procedures accurately, concurrent CDI audits optimize coding and billing processes, resulting in appropriate reimbursement and minimized revenue leakage.
4. Quality improvement
Real-time feedback and collaboration between CDI specialists and healthcare providers facilitate continuous improvement in documentation practices, ultimately enhancing patient care outcomes.
How HITEKS Can Help with Concurrent CDI Audits in Epic
HITEKS, a leader in clinical documentation improvement technology, offers robust solutions to support healthcare organizations in optimizing their concurrent CDI audit processes. Key features and benefits include:
Real-time documentation analysis: HITEKS utilizes advanced algorithms and natural language processing to analyze clinical documentation in real-time, providing CDI specialists with actionable insights during a patient’s stay.
Intelligent automation: HITEKS automates various manual tasks, such as case selection and patient account flags, saving time and streamlining the overall audit workflow.
Data-driven analytics: HITEKS provides comprehensive analytics and reporting capabilities, equipping CDI audit teams with valuable insights to identify trends, measure performance, and drive continuous improvement in documentation practices.
Auditing CDI Staff:
Auditing Queries:
Provider Response:
Concurrent CDI audits offer a proactive approach to ensuring accurate clinical documentation, improving compliance, and optimizing revenue integrity. By addressing the challenges faced by CDI audit teams and leveraging advanced technology solutions like HITEKS, healthcare organizations can unlock the full potential of concurrent CDI audits and drive tangible improvements in documentation accuracy and compliance.
Training & Education for these 2 groups is developed based on the Audit findings:
1.Physician:
Peer to peer education with data driven methodology. Documentation guidelines in line with regulatory requirements
A. Thought leadership insights related to insurance authorization, level of care and Case Mix Index (patient care complexity)
B. Designed based on behavioral research that considers what motivates physicians to adopt change.
C. Customized to high-dollar, high-frequency diagnoses and procedures.
2.CDIS:
Education provided by peers and physician advisors. Regulatory, Compliance and Coding Clinic standards are provided as validation resources.
A. Focused on formulating high quality queries
B. Application of clinical coding conventions and regulations
C. Communication clarity with physician
D. Functional training to elevate queries with use of AI tools
