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Clinical Documentation Improvement
The CDI Program is to improve inpatient clinical documentation. Education and training will be provided to staff members and physicians.

Novant Health has engaged Navigant Consulting, Inc. (NCI) to assist in developing a medical record documentation program that will not only improve, but also sustain clinical documentation that is as complete and accurate as possible.

  • These tools should only be used in conjuction w/ the CDI Program.
  • These tools are valid only for current Medicare fiscal year (FY08).
  • These tools are valid for inpatients paid under prospective payment with MS-DRGs and are are not valid for professional (outpatient/office) documentation and billing.

Below are links to helpful tools for documentation:

Hard copies of the pocket cards are available in Medical Staff Services.

* CC = Complications and Comorbidities
* MCC = Major Complications and Comorbidities
* DRG = Diagnosis Related Group
* MS-DRG =  Medicare Severity Diagnosis Related Group