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Clinical Documentation Improvement (CDI)

Date of Publication:

6/8/2016

Definition:

A program that improves the quality of clinical documentation, regardless of its impact on revenue. CDI programs facilitate accurate representation of health care services through complete and accurate reporting of diagnoses and procedures. This can have an impact on Centers for Medicare and Medicaid Services quality measures, present on admission, pay-for performance, value-based purchasing, data used for decision making in health care reform, and other national reporting initiatives that require the specificity of clinical documentation. Improving the accuracy of clinical documentation can reduce compliance risks, minimize a health care facility’s vulnerability during external audits, and provide insight into quality of care issues.

Source of Definition:

DoD Instruction 6040.42: Management Standards for Medical Coding for Health Records

Last Updated: December 05, 2018
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