Clinical documentation improvement, although not a new program, has made new strides emerging as another strategic step in an effort to improve quality and compliance. The common mantra, “Document, document, and document,” is even more imperative to physician practices than ever before. Effective documentation is the key to successfully combing through all the healthcare initiatives as well as pre- and post-audits.
Keep in mind: It’s not about questioning if a patient’s visit or care was medically necessary, but more about making sure that claims are not denied or audited. In an effort to avoid the onslaught of payer audits, it’s important to implement a CDI program and include a quarterly or yearly practice performance audit plan.