Aging A/R Recovery

Along with our other services, Code Billium (CB) is rapidly becoming a leader in Clinical Documentation Improvement (CDI). We work closely with healthcare providers to ensure that they capture appropriate revenue that might otherwise be missed. By collaborating with coding teams, we help illustrate the severity of illness and risk of mortality for patients, ensuring accurate reimbursement.

What is Clinical Documentation Improvement (CDI)?

Clinical Documentation Improvement (CDI) is the process of reviewing clinical documentation in a patient’s medical records to ensure completeness and accuracy. Proper CDI by a skilled organization like Code Billium (CB) involves analyzing the patient’s diagnosis, diagnostic findings, and disease process to identify any gaps—whether missing, under-coded, or incorrectly coded.

Our CDI specialists bring a unique combination of clinical and medical coding expertise, ensuring that documentation gaps are identified and corrected.

The Importance of CDI

Health systems invest significant resources into patient care, and we help educate providers to accurately document the diagnoses they are treating. Accurate clinical documentation is crucial not only for proper patient care but also for ensuring healthcare organizations receive appropriate reimbursement.

While specialists, lab tests, and diagnostic tests are part of a patient’s medical record, clinical documentation, in the context of CDI, typically refers to the entries made by a medical provider or clinical staff member who is responsible for patient care during inpatient visits.

Even with the advent of electronic health record (EHR) systems, medical providers still hold responsibility for maintaining accurate and detailed clinical information regarding the care they provide.

How Code Billium (CB) Supports CDI

Our CDI specialists are responsible for reviewing patient medical records to ensure the documentation accurately reflects the patient’s current conditions. This ensures proper coding of the patient’s health status, which in turn allows healthcare organizations to receive the appropriate reimbursement for services rendered.

At Code Billium (CB), we are committed to ensuring that healthcare providers capture all the necessary information for proper revenue cycle management, improving both the quality of care and financial outcomes.

If you’re interested in learning more about how Code Billium (CB) can help your organization succeed with Clinical Documentation Improvement, contact us today!