Clinical Documentation Integrity: Why Consistently Providing Effective Clinical Documentation Is Important for Behavioral Healthcare

Healthcare providers require accuracy to conduct operations effectively and ethically. 

Comprehensive medical reporting and clinical documentation integrity are both vertebrae in the Hippocratic backbone of behavioral healthcare.

Technology has streamlined the way healthcare facilities process confidential patient information. It is more important than ever to ensure that data are accurately reported, correctly coded, and securely stored. 

This article aims to define clinical documentation integrity (CDI), outline the importance of CDI, and present how to improve clinical documentation integrity in your behavioral healthcare facility.

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Table of Contents

• Ritten: A Behavioral Health EMR System That Supports Clinical Documentation Integrity 
• What Is Clinical Documentation Integrity?
• Why Is Clinical Documentation Integrity Important?
• 5 Healthcare Stakeholders That Rely on Accurate Clinical Documentation
• 4 Practices That Can Improve Clinical Documentation Integrity

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Ritten: A Behavioral Health EMR System That Supports Clinical Documentation Integrity

At Ritten, we believe the future of behavioral health is data-driven. 

For decades, healthcare providers and clinicians have relied on empirical data to revolutionize the way behavioral medicine is practiced. While this practice is in no way defunct, technology has presented a way to enhance the accuracy of how data is recorded, relayed, and stored. 

Ritten is software expertise that takes full advantage of technological advancement to present providers with the tools they need. We believe in building the future of behavioral EMR software with CDI in mind. 

We provide EMR services for behavioral health facilities, including:

• Substance abuse treatment centers
• Eating disorder centers
• Residential treatment centers
• Therapeutic boarding schools

Join the behavioral health software revolution and transform the way you practice clinical documentation integrity. Book your demo today.

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What Is Clinical Documentation Integrity?

What does clinical documentation encompass?

Clinical documentation (CD) is a repository of all patient information in a medical record housed in a digital or analog record.

CD details:

• Clinical assessments
• Diagnosis
• Client care plans
• Billing
• Medical history 

Clinical documentation is regarded as a legal document that requires authorization to access. It is the core of every patient encounter. Healthcare providers depend on the accuracy of clinical documentation to provide quality standards of patient care that is:

• Precise
• Reliable
• Timely
• Legible

Clinical documentation integrity (CDI), also referred to as clinical document improvement, is the practice of ensuring accurate and comprehensive clinical documentation in client records. 

The American Academy of Professional Coders (AAPC) defines CDI as “the process of reviewing medical record documentation for completeness and accuracy.” 

While clinical documentation may also be recorded on paper, electronic medical record (EMR) systems have advanced the way healthcare providers record and review patient information. This advancement increases CDI when used correctly.

CDI programs supply healthcare providers with:

• A clear patient portfolio that leads to better patient outcomes.
• High-quality data to keep clinicians informed.
• A clearer and more efficient reimbursement process for claims.
• Support and evidence during an audit.

Clinical documentation relies on the credibility of CDI, and that credibility relies on compliance. CDI compliance is accomplished by adhering to the code of conduct, and legal, ethical, and best practice standards for documentation, authorization, billing, and coding. 

Examples of compliant and credible CDI practices include:

• Querying physicians to avoid overly broad or incomplete clinical documentation
• Concurrently reviewing patient information with the patient to avoid inaccurate reflection of patient condition, treatment, and outcomes
• Continually educating facility staff on documentation practices, coding guidelines, and regulatory requirements
• Developing document improvement initiatives to enhance the quality and integrity of clinical documentation

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Why Is Clinical Documentation Integrity Important?

The efficacy of CDI is dependent on compliance and credibility. Clinicians and staff rely on accessible and accurate patient information to ensure the best patient outcomes. If patient information is inaccurate or mishandled, the credibility and compliance of the whole system may be held in question. 

The use of electronic health record (EHR) systems eases the burden of navigating administrative duties regarding patient care and claim submission. Still, the burden of responsibility lies with the medical provider. 

CDI, CDI specialists, and EMR systems help providers maintain this responsibility by creating a system that reviews patient records to accurately record and reflect clinical documentation. 

CDI has a direct impact on patient care. Not leveraging CDI could directly harm patients and the related healthcare facility and potentially lead to problems like:

• Incomplete reimbursement for claims
• Improperly coded documents
• Miscommunication with other healthcare practitioners
• Accusation of fraud 
• Poor facility reputation

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5 Healthcare Stakeholders That Rely on Accurate Clinical Documentation

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#1: Litigators 

CDI is essential to the financial health of healthcare providers and facilities. 

Lawsuits are often common in medical and behavioral health practices. Proper documentation may: 

• Provide litigators with accountability information
• Help a facility avoid wrongful accusations and lawsuits
• Help protect behavioral health practitioners from civil, criminal, and administrative penalties and litigation

On the opposite side of the spectrum, incorrect or misreported CDs could pose issues for a facility’s litigation team during a lawsuit. 

In the event of a medical error disclosure, the use of correct wording for clinical documentation is crucial for the litigation team. CDI specialists may work alongside litigators to help providers fully disclose medical errors in a way that clears the facility of fraud or malpractice. 

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#2: State Regulators

Documentation of medical services and CDs must comply with state and federal laws to receive reimbursement. 

According to the Centers for Medicare and Medicaid Services (CMS), behavioral health services are required to:

• Meet their state’s Medicaid program rules
• Reflect medical necessity and justify treatment
• Reflect active treatment
• Be correct, concise, and accurate regarding all patient details
• Be legible, signed, and dated
• Be maintained and accessible for review
• Be coded correctly for billing purposes

Per these same regulations, electronic health records (EHRs) require extra precautions that must:

• Ensure records reflect the uniqueness of the patient’s self-reporting
• Provide a date and time stamp on all patient notes 
• Identify the clinician making edits to patient records

Clinical documentation integrity (CDI) helps providers operate inside these guidelines, as well as keep a record of compliance. 

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#3: National Accreditors

National accreditors, like The Joint Commission, help maintain quality assurance, guideline adherence, and ethical compliance of behavioral health facilities and services. 

Well-kept CDIs may help providers establish accreditation standards during an audit. This reduces the risk of auditors finding potential legal, ethical, and practice issues that could jeopardize the facility’s accreditation. 

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#4: Payers

Insurance payers rely on a complete and accurate assessment of patient care to provide reimbursement. 

Coding and billing must exactly reflect the complexity and acuity of all patient care so that insurance payers may reimburse facilities on behalf of the patient.

Payers may sometimes use clinical documentation inconsistencies as an advantage during denials. This creates a strong imperative to ensure that all data is complete and accurate.

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#5: Clients

CDI supports effective communication between providers and clinicians by accurately capturing and recording:

• Medical history
• Diagnosis
• Treatment 
• Outcomes

Providers rely on precise and accessible patient data to enhance patient care while protecting patients, staff, and the credibility of the facility.

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4 Practices That Can Improve Clinical Documentation Integrity

Clinical documentation integrity may be necessary to ensure the best patient and provider outcomes. An EMR system with strong clinical documentation integrity may provide your facility and its stakeholders with accurate and improved documentation

A good EMR system can help your clinical staff work smarter, not harder, with precision that ensures quality patient outcomes and financial security. 

Ritten provides simple software for any degree of complexity. 

We are an electronic medical record system that aims to go beyond other EMR systems. Our software can provide behavioral healthcare providers and facilities with the power to improve CDI and optimize workflow to unveil hidden insights about your practice. 

Provide your clinicians with powerful CDI assistance powered by Ritten. Book a demo today.

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#1: Have Standards Throughout Your Practice or Facility

Implementing ethical standards when practicing clinical documentation integrity can protect your facility, clinicians, stakeholders, and patients. 

The standards you establish for your CDI system should:

• Consistently facilitate accurate and complete documentation within all aspects of records including care, data, and coding
• Act by regulatory standards and requirements when reporting healthcare data elements for external purposes (e.g. reimbursement, purchasing initiatives, administrative uses, and research)
• Query providers when clarification or additional information is needed to complete or correct documentation to avoid conflicts, inconsistencies, or incompleteness
• Never condone or support practices that may fraudulently report information with the intent of increasing payment, skewing data, misreporting quality issues or insurance policies
• Continually educate clinicians and staff on the appropriate methods of reporting, recording, and coding CD

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#2: Utilize an EMR System That Supports Clinical Documentation Integrity

You’ll want to find an EMR system that allows customizable documentation so your staff can work accurately and efficiently while remaining on the same page with other team members. However, not all EMR systems are built alike. 

Features you should look for in an EMR system that provides a CDI program include:

• A user authentication and authorization management
• A record system that tracks audit logs (to see who changed what and when)
• An optimal default security setting
• The inability to change, overwrite, or delete log events
• The ability to detect the alteration of a log
• The ability to ‘time out’ applications that have experienced a period of non-use

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#3: Train Employees on How to Effectively Use Your EMR System

Train staff to become knowledgeable about the ERM system and CDI practices. Educate them on what best practices such as:

• Acceptable copy and pasting practices
• Inconsistencies in documentation that payers may claim in denials 
• Critical elements of clinical documentation like medical history, progress notes, and discharge summaries

Training staff to consistently and correctly document clinical information the first time around can save time and money. 

Steps to consider when training staff on a new EMR system may include:

• Identifying employee computer skills when providing basic training
• Only training employees on the areas they are going to use
• Conducting post-implementation feedback surveys
• Utilizing the training resources provided by your EMR service provider

At Ritten we provide our clients with a team of onboarding specialists that will help guide your staff through every detail. Our in-depth training ensures that even your least tech-savvy team member will be able to use our software.

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#4: Hire a Clinical Documentation Integrity Specialist

Clinical documentation integrity specialists (CDIS) help bridge the gap between clinical and coding language to streamline healthcare workflow.

CDIS are generally certified clinicians who collaborate with healthcare providers to code patient information. 

In addition, CDIS will:

• Evaluate and translate health records into coded data.
• Communicate with providers regarding documentation.
• Educate providers about identification processes to facilitate the accurate application of code sets.
• Impart clinical and coding knowledge to improve the understanding of CDI to other team members.
• Understand the information relating to SOI, ROM, case mix, and the impact of procedures on a billed document.
• Gather and analyze pertinent document findings to develop plans for process improvements.

Who can become a CDIS?

An ideal CDIS candidate would be a nurse who has at least five years of acute care experience or a registered health administrator or technician (RHIA/RHIT) with five recent years of medical coding experience. 

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