Goals and objectives of CDI
The primary purpose of Clinical Documentation Improvement (CDI) is concurrent review of the
medical record to increase the accuracy, clarity, and specificity of provider documentation. The
clinical language contained within a medical record cannot always be matched to a
corresponding ICD-9-CM or ICD-10-CM/PCS code. The CDI specialist (CDIS) identifies
documentation opportunities and collaborates with both clinical and coding staff to improve the
accuracy of coded diagnoses and procedures representing the patient’s episode of care. A
precise medical record captures the clinical severity of a patient’s condition, which can impact
quality metrics and reimbursement and provides justification for the expenditure of hospital
resources.
Although many different professionals are employed as CDISs (e.g., nurses, HIM/coding
professionals, physicians, etc.), a CDIS must have knowledge of coding conventions combined
with a strong clinical background and excellent interpersonal skills. Coding is not the primary
objective of CDI; rather the CDIS works to provide coding staff with a complete and
unambiguous medical record through communication with the treating medical team.
Traditionally, HIM/coding professionals have assigned ICD-9-CM codes to provider
documentation a few days after discharge or at the end of an episode of care. Coding or
medical record review that occurs after patient discharge or at the end of the episode of care is
referred to as retrospective. However, an inability to match provider documentation to ICD-9-CM
codes during retrospective review can delay submission of the claim for payment. The goal of
most organizations is to keep their bill hold (i.e., the number of days a claim is held following
discharge before payer submission) to four days or less; however, the increasing complexity of
hospitalized patients and federal healthcare regulations makes it difficult for organizations to
maintain a low volume of records on bill hold.
Concurrent review of the medical record, which occurs during the episode of care, can increase
the accuracy of provider documentation since the provider is at his or her highest degree of
familiarity with the particulars of the case. It also improves bill hold times as a consequence.
The role of the CDIS is to review the entire episode of care to determine the specific reason for
the encounter as well as all clinically significant conditions that existed at the time of the
encounter or developed during the encounter. CDISs’ facilitate collaboration between the
healthcare provider and the coder to achieve complete and accurate documentation and code
assignment for the reporting of diagnoses and procedures as required by the ICD-9-CM Official
Guidelines for Coding and Reporting.
While more accurate hospital reimbursement often results from the work of CDI specialists, it is
not the sole objective. CDI specialists can directly and indirectly impact all of the following:








1
Compliance with patient safety initiatives
Professional (i.e., physician) reimbursement
ICD-9-CM and ICD-10-CM diagnosis and procedure code assignment
DRG assignment, such as MS-DRGs and APR-DRGs
Severity of Illness (SOI) and Risk of Mortality (ROM) scores
CMS quality measures (i.e., “core measures”) reporting accuracy
Facility efficiencies, value, and quality outcomes in the delivery of healthcare
Medical necessity of the appropriate level of care (e.g., observation or inpatient) or
specific treatments
ACDIS May 2012



Physician and hospital profiles, available on public websites such as healthgrades.com
and hospitalcompare.hhs.gov
Claims data used in CMS initiatives such as the readmission reduction program and the
Value Based Purchasing (VBP) program
Centers for Program Integrity (CPI) and private payer initiatives that focus on integrity
fraud and abuse issues (e.g., Medicare RAC, Medicaid RAC, etc.)
When initiating or revitalizing a CDI department it is important to understand the organizational
objectives of the institution. Most CDI departments have limited resources and must focus on a
few of the review areas listed above. As CDI departments mature, they often incorporate
additional review areas from the above list.
Often the primary goal of hospital administration regarding CDI is incremental reimbursement,
increasing revenue through improved provider documentation leading to the capture of
complications/comorbidities (CC) and major CCs (MCCs). CC/MCC capture affects the severity
of the case, corresponding to higher resource consumption and higher reimbursement under the
MS-DRG system.
When the CDIS finds clinical indicators of an incomplete, vague, or missing diagnosis that
meets coding guidelines of an “other” or secondary diagnosis, or encounters conflicting
documentation, he or she works with the attending provider to clarify the documentation so it
can be captured by an ICD-9-CM or ICD-10-CM/PCS code. Although a CDIS may engage in
many different types of communication with the medical team, any communication regarding
clarification of a specific medical record is referred to as a “query,” according to the American
Health Information Management Association (AHIMA) 2010 practice brief, “Guidance for Clinical
Documentation Improvement Programs.”
The purpose of a physician query and/or physician clarification is to ensure that all diagnoses
and treatments are documented in the medical record to the highest level of specificity
substantiated by the patient’s clinical presentation and corresponding treatment. Complete,
specific, and accurate provider documentation enhances a coder’s ability represent the medical
encounter with ICD-9-CM, ICD-10-CM/PCS, and CPT-4 codes.
CDI specialists also provide education to physicians and other healthcare providers regarding
the importance of accurate and consistent documentation throughout the medical record. This
education is often most effective when delivered to the individual provider on the hospital floor
while discussing a specific patient. When possible, many CDISs join providers during their
rounds, during which a provider completes his or her daily assessment of the patient’s condition.
Collaboration during rounding expedites the documentation process as the provider receives
real-time feedback while making an entry into the medical record. This process helps the
provider understand how his or her documentation will be interpreted by coding and ensures
that the provider’s clinical intent will be accurately captured.
The goals and objectives of a CDI department also include collaborating with other departments
and bridging the gap between HIM/coding staff and providers. Collaboration with other
departments is critical to the continued success and growth of a CDI department. Examples are
described below.
Collaboration
As a CDI department matures, creating partnerships with other departments can positively
impact an organization’s finances and publicly reported data as well as decrease audit risks.
Examples of how a CDIS can assist other departments include the following:
2
ACDIS May 2012
Case Management (CM)
 Providing CM staff with the geometric length of stay (GLOS) associated with the working
DRG. This helps to ensure that discharge coincides with the GLOS to avoid expenditure
of non-reimbursed hospital resources. Every MS-DRG has an associated relative weight,
GLOS, and average length of stay (ALOS). CMS uses the relative weight, multiplied by
the organization’s blended base rate, to determine an organization’s reimbursement.
Organizations that accept Medicare beneficiaries agree to accept the MS-DRG rate as
full payment for rendered services. A key component of MS-DRG reimbursement is the
inclusion of anticipated room and board charges based on the GLOS associated with the
principal diagnosis and applicable CCs or MCCs. Discharge of a patient within the
GLOS associated with the working MS-DRG can result in greater profitability.
Conversely, when the LOS extends beyond the GLOS associated with the working MSDRG, the hospital may lose revenue as the hospital continues to expend resources that
will not be recouped from the payment. When reviewing a patient without a CC or MCC
the CDIS ( in conjunction with CM) can assist in determining whether the extended LOS
is possibly due to an incomplete, vague, or missing diagnosis, as opposed to discharge
planning issues.
Coding
 Ensuring the medical record presents an accurate clinical picture by querying for vague,
missing, and/or incomplete diagnoses during the hospital stay and/or after discharge but
prior to billing. Coders assign ICD-9-CM codes based on provider documentation in the
medical record. However, the medical record does not always accurately reflect the
intent of the provider and/or the patient’s clinical picture, leading to inaccurate or
unspecified code assignment. Coders often are held accountable for increased bill hold
times and delays in accounts receivable (AR). CDI specialists can positively impact bill
hold times by initiating and completing queries on a concurrent basis, which allows
coders to work from completed records.
 Analyzing audit data i.e., Program for Evaluating Payment Patterns Electronic Report
(PEPPER) and validation audits with their coding manager regarding MS-DRG
assignment based on principal diagnosis selection, code sequencing, and identification
of secondary diagnoses. Both coding and CDI should be involved in the review of high
vulnerability claims and outliers.
 Participating in/organizing joint educational efforts, especially regarding annual updates
to the IPPS and quarterly issues of Coding Clinic. This ensures that both coders and
CDIS are using the most current guidelines when reviewing the medial record.
 Working collaboratively with coding regarding ICD-10-CM/PCS implementation and
educational efforts, with a particular focus on educating providers on the need for
increased specificity.
Compliance/ denials management/revenue cycle/RAC team
 Assisting with internal reviews of RAC findings to either appeal the RAC findings and/or
adjust work flow processes to prevent future similar claims errors.
 Developing a monitoring process for MS-DRGs identified as high risk for payment error
by Comprehensive Error Rate Testing (CERT) review and the RAC though regular
review of their organizational PEPPER data. CDI staff can assist in the development of
policies to address organizational vulnerabilities and a standardized
monitoring/proficiency process.
3
ACDIS May 2012



HIM



Assisting in the development and review of query templates and organizational
definitions to ensure both legal and industry compliance.
Developing educational sessions based on compliance monitoring of coding and CDI
quality to ensure consistency in querying and coding practices within the organization.
Involving the compliance department with provider educational efforts. Compliance staff
can review the CDISs’ educational tools to ensure they do not erroneously force or
pressure providers to document using particular diagnoses that increase reimbursement
(i.e., promote “leading”). Compliance should reinforce the requirement that queries must
be answered, but also ensure that the provider is not obligated to agree with the
recommendations of CDI staff. Lastly, compliance should review any initiatives in which
the provider is incentivized for cooperation with CDI efforts.
Providing input on electronic medical record (EMR) design and implementation. CDISs’
should focus on products used by the medical staff such as CPOE, as the transition to
electronic orders can result in lost documentation that was previously captured on paper
order forms.
Providing feedback regarding inaccurate use of copy and paste functions in which
obsolete or inaccurate documentation is perpetuated through the medical record.
Participating on the medical record and/or forms committee. CDISs should be involved
due to their skill in reviewing the concurrent medical record and their insight into
documentation prompting tactics that could be considered “leading,” or guiding the
provider to a particular conclusion.
Providers
 Educating the medical staff regarding the importance of their documentation on both
professional and facility reimbursement, and developing tools that incorporate elements
which can result in positive outcomes and appropriate reimbursement for both. The data
elements that impact both facility and professional reimbursement include the following:
o Review of Systems
o History of Present Illness and Past Medical History
o Daily progress notes
o Discharge summary
o Nurses’ notes
o Death notes
 Educating physicians on their difference between ICD-9-CM procedure codes and CPT
codes, including the impact of ICD-9-CM codes on core measures.
 Rounding with the medical team and helping them translate their clinical findings into
diagnoses and/or terminology that can be captured by ICD-9 and/or ICD-10 codes.
 Educating the medical staff on ICD-10-CM/PCS and how documentation requirements
will change with the new coding system.
 Educating providers on the impact their documentation has on hospital and physician
quality scores.
Quality
 Assisting with requirements under Value Based Purchasing (VBP). In fiscal year 2013
organizations must contribute one percent of their annual MS-DRG payment into a
common pot that will be used to reward organizations that score well on specific quality
measures. The number of quality measures and the contribution rate will increase in
4
ACDIS May 2012



both fiscal years 2014 and 2015. Many of these quality metrics are triggered by the
presence of particular ICD-9-CM codes.
Assisting with accurate capture of the expected mortality or acuity of the patient
population. Collaboration between quality and CDI departments can positively impact the
mortality index, which is the ratio of expected deaths compared to actual deaths. Many
calculations of mortality are dependent upon the SOI and ROM values associated with
the case, which are calculated using an APR-DRG grouper. CDI staff can review
medical records to ensure accurate SOI/ROM assignment. Note that a focus on
SOI/ROM involves more continued stay reviews than traditional MS-DRG review as
multiple CCs and/or MCCs must be captured to ensure the highest SOI/ROM ratings.
Working with providers to ensure that Present on Admission (POA) indicators are
correctly assigned to complex diagnoses like pneumonia and sepsis when the diagnosis
occurs later during the admission but the symptoms were present on admission. POA
indicators are also used to identify Hospital Acquired Conditions (HAC). Often signs and
symptoms of a condition exist on admission, but a corresponding diagnosis may not
appear in the history and physical, requiring clarification by the CDIS of the condition’s
status on admission when documented more than 24 hours into the admission. Note that
if these particular ICD-9-CM codes appear in the medical record but were not identified
as POA, the hospital is unable to use that ICD-9-CM code as a CC or MCC.
Obtaining documentation for accurate reporting of AHRQ Patient Safety Indicators (PSI),
a set of indicators providing information on potential hospital complications and adverse
events following surgeries, procedures, and childbirth. For example, if a physician
documents “acute respiratory failure” it will trigger PSI 11—(Postoperative respiratory
failure). A CDI specialist can provide education to the provider on the appropriate uses
of acute respiratory failure following surgery caused by a disease (which is not a PSI) vs.
acute respiratory failure following surgery caused by the operative procedure (a PSI).
Additionally, CDI staff can review records to capture AHRQ diagnoses, some of which
are CCs, but the presence of which may impact mortality metrics. A CDIS can provide
concurrent feedback to the medical team when a particular diagnosis may result in a PSI
issue or a quality metric deficiency, and/or refer these cases to the quality department
for follow up.
Utilization Review
 Collaborating with UR to ensure correct assignment of the principal diagnosis when an
inpatient admission follows an outpatient procedure or outpatient episode of care.
Additionally, UR staff can educate CDI staff regarding the Medicare three day rule, which
can impact MS-DRG assignment if an outpatient procedure becomes “linked” to an
inpatient admission, causing the procedure to be unrelated to the principal diagnosis.
 Assisting with the establishment of medical necessity, especially for short stay
admissions of two days or less. This includes analyzing PEPPER data in conjunction
with UR to ensure strict adherence to screening criteria for symptom based MS-DRGs
that are prone to short stay admissions of less than two days. These claims may result in
denials due to a lack of medical necessity. CDI and UR should develop a process to
review a sample these vulnerable claims at regular intervals to confirm that medical
necessity criteria was met, and determine if additional documentation could have
supported a more definitive principal diagnosis and MS-DRG assignment.
 Ensuring provider documentation reflects the exacerbation or increased acuity of a
chronic condition necessitating inpatient care.
 Querying for the underlying etiology of a symptom principal diagnosis (e.g., chest pain,
syncope, abdominal pain) to support inpatient care.
5
ACDIS May 2012
Nursing/patient safety
 Working cooperatively with the bedside nurse providing direct patient care. The bedside
nurse has insight into the patient’s condition as well as the treatment plan that may not
be fully conveyed in the medical record. Informing the bedside nurse when a query is
issued may result in higher provider response rates as the nurse can bring the presence
of the query to the attention of the medical team. In addition, proper documentation of a
diagnosis through a physician query can help clinical staff better understand the
treatment plan.
 Alerting appropriate clinical staff or informing nursing staff whenever quality of care
issues arise. These issues may include medication errors, abnormal lab values, or
inconsistencies in documentation (i.e., the provider refers to the left side in one progress
note and the right side in another progress note when a unilateral event occurred).
Although these discrepancies and findings may not impact ICD-9-CM code assignment,
they can compromise the quality of patient care if not addressed.
6
ACDIS May 2012
Bridging the gap
The role of the HIM/coding professional is evolving. More than ever coded data impacts quality
reporting (i.e., Value Based Purchasing, facility/physician profiling). However, coding rules and
guidance are often outpaced by clinical practice. This leads to discrepancies between physician
intention and what can be captured by the limitations of ICD-9-CM codes. Although ICD-10CM/PCS may remedy some of the shortcomings of ICD-9-CM, coders are still limited by their
ability to report codes from physician documentation that is often imprecise or non-specific.
Often the documentation is sufficient enough to support the clinical picture, but may lack the
specificity needed to report an appropriate ICD-9-CM/ICD-10-CM/PCS code.
The role of the CDI specialist is to bridge the gap between the physician and coder—i.e.,
between clinical practice and the assignment of ICD-9-CM/ICD-10-CM/PCS codes. Through the
work of the CDI specialist, a coder is better equipped to find the clinical intent of the provider. A
mature CDI department can assist the medical team in providing concise, accurate
documentation that meets both facility and professional coding needs without overwhelming the
medical staff.
7
ACDIS May 2012