Back in November, I wrote about clinical documentation improvement (CDI) in the medical practice and the importance of this critical step in adopting ICD-10. It will not only improve diagnosis coding, but also compliance for procedures and services reported by the practitioner.

I have worked and am working with medical practices of various sizes to develop a solid CDI process, not only to improve coding and documentation for ICD-10, but to develop a protocol to support all services provided to the patient. Right now I am in the middle of developing a process for a large medical practice and would like to share the steps I have taken in CDI development. In the medical practice, it can be more difficult, as there are typically not electronic CDI tools or software programs to perform the necessary data mining to assist with CDI. But it can be accomplished.

First, let’s review the steps associated with implementation of a quality CDI program in a medical practice:

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