AI Clinical Documentation Integrity
AI Clinical Documentation Integrity (CDI) products leverage artificial intelligence to review and evaluate clinical documentation in support of appropriate patient care, billing, and compliance with regulatory requirements.
These solutions can operate at the point of care, ensuring the documentation reflects the patient-clinician conversation and available clinical data, and supports the assigned medical codes. They can also operate post-encounter, between the medical coding and billing steps, to review the documentation against what has been coded and surface suggestions for revenue and quality opportunities. Many of these solutions include built-in functionality to suggest potential diagnoses that may have been missed based on information in the patient record.
While similar in concept to risk adjustment solutions, AI CDI products are predominantly used in a fee-for-service context to ensure more accurate and complete billing and improve care quality.