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Implementing integrated clinical documentation improvement (CDI) and computer-assisted coding (CAC) technology platforms can help hospitals achieve more positive results than would be realized using CAC alone. The most significant impact CDI technology has on the CAC component of an integrated platform is creating high-quality documentation, and documentation has a direct impact on quality of care, compliance, and reimbursement.

In order for documentation to be considered of “high quality,” it must be:

  • Complete
  • Precise
  • Legible
  • Consistent
  • Clear
  • Reliable
  • Timely

With an integrated CDI and CAC platform, any user can review high-quality, codified documentation that features  the specificity necessary to reflect the level of care accurately. Quality documentation can improve the accuracy of the CAC results returned to the coder. With better CAC results, the coder becomes more of a validator, and a rise in productivity is achieved. In addition, providing standardized documentation shared across users helps identify areas for potential improvement in preparation for automated coding and ICD-10. This drives the holistic success of the CAC component.

Staff Performance

An integrated CDI/CAC platform also can help identify those clinicians who may need more training in ICD-10 documentation principals. If a platform utilizes a single natural language processing (NLP) engine to analyze and assign ICD-9 and ICD-10 codes for both the CDI specialists and the coders, administrators can glean a unique perspective on a hospital’s clinical documentation.

For example, if the NLP engine provides a CDI specialist with only an ICD-9 code for a “codeable” event and doesn’t provide an ICD-10 code for the same event, chances are the clinician will draft acceptable documentation for the ICD-9 world only. The documentation might be missing the level of specificity of laterality that is required for the NLP engine to build the ICD-10 code.

The integrated platform will allow users to build a simple query to identify all “codeable” events that have an ICD-9 code but not an ICD-10 code. This provides an efficient mechanism to identify those clinicians who are documenting well in the ICD-9 world, but need more training to be successful in the ICD-10 world.

Building Queries

The ability to build queries within an integrated platform is advantageous because the system can break down information silos and increase communication and information-sharing between the CDI specialists and the coders. Instead of hallway conversations, telephone tag and email exchanges, the CDI specialist and coder can be reviewing documentation that may justify a query simultaneously. This allows hospital teams the chance to leverage each member’s expertise and unique perspective, and it defines a unified approach to the query development process. Increased collaboration may even reduce the number of queries sent to the physicians, and in turn increase the query response rate.


An integrated platform has the flexibility to be deployed in pieces. After overseeing many integrated platform implementations, it has become readily apparent to me that the CDI component is the piece that should be implemented first. Many hospitals find that deploying CDI first improves documentation, allowing for the maximization of CAC results. The most significant benefit of this approach is that it provides a hospital with the ability to focus on the quality of its documentation prior to implementing CAC, allowing for the obtaining of optimal results from the NLP process and the automatic assignment of codes.

CDI is a critical initiative that is helping hospitals across the country become better prepared for the challenges of ICD-10. It is helping to identify documentation deficiencies, prepare organizations for audits, single out physicians who need to be trained, and prime clinical documentation for the CAC process. Hospitals utilizing an integrated CDI and CAC technology platform are seeing positive results in quality, staff performance, and reimbursement in the short time leading up to the ICD-10 implementation date next year.

About the Author

Krista Jaroszewski has more than 20 years of experience in healthcare operations and technology, specifically in the areas of product management, project management, implementation, accounts, and management. She has served as director of product management and product manager for Precyse since 2006, with specific focus on the CDI, transcription and coding product suites. Krista also has served as the director of transcription operations for Precyse from 2004-2006. Prior to her work at Precyse, Krista served a variety of operational and product roles at Matria Healthcare, WebMD, Emory, and the New Image Orthodontic Group. Krista received her Bachelor’s degree from The Ohio State University and performed graduate work at DePaul University. 


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