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What Is CDI and How Does It Impact You?

Source: Emily Hill, PA, AAPM Coding Consultant
Date: June 6, 2018


CDI (Clinical Documentation Improvement) has been described as the process of improving healthcare records to ensure improved patient outcomes, data quality, and accurate reimbursement. Hospitals began CDI programs as a response to the advent of DRGs (Diagnosis Related Groups) as a form of reimbursement. Most physicians have experienced the request for supplementary documentation to support additional or more specific ICD codes to enhance hospital reimbursement and data collection.

The ability to collect and track data has resulted in more robust and expanded CDI programs. Although CDI historically has been a hospital-based program, it is moving to physician practices as its importance is recognized. The impact of CDI today may be described as the completeness, consistency, organization and accuracy of the medical record, reflecting the physician's clinical judgment and medical decision making. The overall goal of a CDI program is to improve clinical documentation, coding, and reimbursement.

From a reimbursement perspective, an effective CDI program can reduce denials and improve the appeals process using improved clinical documentation. Clinically, it results in a more useful medical record and more meaningful patient information and data.

Initiating a program in your practice requires thought and planning but it doesn't have to be overwhelming. Over the next several months, we'll focus on the steps of assessment, implementation and maintenance of an office-based CDI program. Improving documentation is inherently a good goal with down-stream benefits of improved reimbursement and an effective clinical record.

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