What Is Clinical Documentation?

Clinical documentation is the information a person responsible for a patient’s medical care enters in a medical record, which is a repository for an individual’s health information. The entries contained in the medical record may be authored by a physician, dentist, chiropractor, or other healthcare professional. Regulations, accreditation requirements, internal policies, and other rules may define who is allowed to document in the medical record in specific cases.

What Is Clinical Documentation Improvement?

Clinical documentation improvement (CDI) is the process of reviewing medical record documentation for completeness and accuracy. CDI includes a review of disease process, diagnostic findings, and what documentation might be missing. A CDI specialist often has both clinical and medical coding backgrounds. Bridging the gap between clinical documentation and accurate coding drives CDI programs.

While reports from laboratory tests, diagnostic tests, and consultations with specialists may also be housed in a patient’s medical record, “clinical documentation” in the context of CDI generally refers to the entries made by a provider or clinical staff member who is responsible for the patient’s care during a face-to-face visit.

CDI programs have been a part of healthcare since long before the term was uttered. However, they got a boost in popularity around 2007 when the Centers for Medicare & Medicaid Services (CMS) implemented Medicare Severity Diagnosis Related Groups (MS-DRGs). MS-DRG is a payment model used for reimbursement under Medicare’s Inpatient Prospective Payment System (IPPS). Hospitals realized that accurate and thorough diagnosis code reporting increased reimbursement and reduced compliance risks with IPPS. As a result, CDI programs were organized so that a team of nurses could concurrently review the inpatient medical record documentation and query a provider concerning anything ambiguous or not complete prior to claim submission. This practice resulted in more accurate billing for the facility, and the CDI trend took hold.

While CDI may have gotten its start in the inpatient environment, outpatient providers have recognized the benefit and started programs, as well. The natures of inpatient and outpatient CDI programs vary, but they share a goal of increasing the accuracy of clinical documentation and coding.

Purpose of a Clinical Documentation Improvement Program

A clinical documentation improvement program is a process designed and implemented with the purpose of achieving accurate and thorough medical record documentation.

Why are CDI programs needed? In many ways, the use of electronic health record (EHR) systems has eased the burden on providers and hospitals of navigating the administrative duties surrounding patient care and claim submission. However, the responsibility of medical record documentation — the entry of clinical information concerning care rendered to a patient — will always remain with the medical provider. To help providers succeed in this task, a CDI specialist is responsible for reviewing a patient’s medical record to ensure documentation reflects the specificity of current conditions to allow for accurate coding of the patient’s health status.

Impact and Benefits of a CDI Program in the Inpatient Setting

CDI can improve the accuracy of coding and billing for inpatient facilities, which will result in more accurate reimbursement. The financial impact of an inpatient CDI program is not limited to initial payment of claims, though. Improper claim submissions resulting from poor documentation can result in unfavorable audits, which could require facilities to pay a fine, return money erroneously collected from payers, or both. Consequently, the role of CDI in claims processing in healthcare facilities includes both increasing the accuracy of initial reimbursement and preventing expensive consequences from reviews by authorities.

Hospitals are familiar with and subject to various types of audits. To guarantee their facility’s documentation withstands auditor scrutiny, a CDI specialist needs to be knowledgeable about the federal regulations regarding fraud, abuse, and compliance, as well as payer requirements for clinical presentations of diseases. For instance, the department of Health and Human Services (HHS) tasks the Office of Inspector General (OIG) with identifying, by way of the OIG’s Work Plan, incidences of fraud, waste, and abuse within medical claims submitted to the federal government.

In one example of poor documentation practices in healthcare facilities — and documentation not supporting coding — an OIG audit was released in July 2020 that determined hospitals overbilled Medicare $1 billion by incorrectly assigning severe malnutrition diagnosis codes to inpatient hospital claims. In 200 claims reviewed in this audit, 164 contained severe malnutrition diagnosis codes when they should have had other forms of malnutrition or no malnutrition diagnosis codes at all. OIG recommended that Medicare collect the overpayments from providers where possible. A CDI specialist can help stop this sort of improper reporting and confirm patients have accurate diagnoses in the medical record by reviewing documentation and training providers and coders on the documentation required to support malnutrition diagnoses and codes.

Audits on the OIG’s radar change from year to year. CDI specialists and others working in healthcare should review the OIG Work Plan regularly to keep up to date.

How CDI Can Help Maximize Revenue

Preventing unsupported diagnoses from being reported on a claim is one benefit of inpatient CDI programs. But ensuring all conditions that are clinically supported get reported is equally important because of how inpatient facility reimbursement works. To fully grasp how a CDI program can be successful for an inpatient facility from a financial perspective, it is necessary to understand Medicare’s DRG payment system. Many non-Medicare payers use an adaptation of this DRG payment system, as well.

Diagnosis related groups (DRGs) are just that: groupings of a patient’s diagnoses that are related and impact care during an inpatient stay. The patient’s principal diagnosis and up to 24 secondary diagnoses, including comorbid conditions (CC) or major comorbid conditions (MCC), determine the DRG assignment. The scenario below demonstrates the connection between diagnoses, DRGs, and reimbursement.

Scenario 1: Example of diagnosis grouping in an inpatient facility

A 52-year-old male patient was admitted to an acute care hospital with a diagnosis of chronic obstructive pulmonary disease (COPD) with acute exacerbation. After a four-day stay receiving treatment, the patient was discharged. If a claim had been submitted with this single condition, the DRG assignment would have looked like this:

However, when a CDI specialist reviewed the documentation before discharge, they noticed that on the second day of the four-day inpatient stay, the patient was put on ventilator assistance. The lab report showed P02 (partial pressure of oxygen) <55, PCO2 (partial pressure of carbon dioxide) >50, and pH (power of hydrogen) <7.35. A query was sent to the attending physician. The patient was discharged on day four with the diagnoses of COPD with acute exacerbation and acute respiratory failure with hypoxia and hypercapnia resulting in more accurate DRG assignment:

* While payment amount based on DRGs is unique to each hospital’s contract with a payer (private and government), this example uses estimated reimbursement amounts to show that, the more severe the DRG grouping, the higher the reimbursement to that facility is expected to be.

In the scenario above, in response to the CDI specialist’s query, the provider documented with greater specificity the diagnoses present and treated during this admission. This CDI process resulted in accurate reimbursement to the facility for the severity of illness of this patient.

How CDI Can Improve Patient Care

In addition to the financial impact of an inpatient CDI program, the benefit to the overall well-being of the patient is significant as well. Poor records can impact patient care in a healthcare facility by affecting continuity and quality of care. The concurrent review of documentation by the CDI specialist enhances communication between all providers involved in the patient’s care in a timely manner, which may reduce the length of stay for the patient.

Similarly, a CDI program can help reduce avoidable readmissions by improving communication and care coordination between patients and their caregivers at the time of discharge. Payers have taken note of these benefits and created programs to promote them. For instance, the Hospital Readmissions Reduction Program (HRRP) is a value-based purchasing program that reduces payment to hospitals with excess readmissions. In conjunction with HRRP, CMS assesses a broad set of healthcare activities that affect patients’ well-being.

Impact and Benefits of a CDI Program in the Outpatient Setting

A CDI program in the outpatient setting can have just as much financial impact as in the inpatient setting. Provider offices rely on a healthy revenue cycle to ensure expenses and salaries are paid. Claim denials or amendments because of improper code submission can be disruptive to the timely receipt of payment for services rendered. The primary focus of a CDI program for physicians in an office or outpatient environment is to help prevent these denials and amendments while also ensuring documentation is complete for clinical purposes.

Accurate and specific clinical documentation is essential to proving medical necessity for the CPT^® codes submitted on a claim. CDI specialists can play a role in preparing providers and coders for coding and coverage changes that affect documentation requirements. After updates, the CDI specialist can continue to assist by reviewing documentation and claims to validate the diagnosis codes accurately reflect what the provider recorded and support medical necessity for the level of E/M code reported on the claim. If a payer audits the claim later, the medical practice can feel confident they have done their best to be accurate and can share their process with the auditor to prove their dedication to compliance.

The role of CDI extends beyond documentation for services such as office visits, immunizations, and minor procedures in the doctor’s office; patient outcome-based quality services are becoming more meaningful to both the patient and the physician. For instance, if a physician or physician group is eligible to participate in the Merit-based Incentive Payment System (MIPS), which is part of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, positive or negative payment adjustments could be realized based on reporting of high-value, patient-centered care.

Table 1 shows examples of 2024 MIPS quality measures. The descriptions are only summaries, but the level of detail required is already evident. A CDI specialist can be instrumental in guaranteeing that the clinical documentation includes the necessary information to meet the criteria of MIPS measures. By running reports of ICD-10-CM codes submitted on claims, reviewing the medical documentation, educating the provider on certain measures that have not been met, and educating the coding team to report these measures, the CDI specialist bridges the gap between clinical documentation and medical coding. Again it is clear that thorough clinical documentation can be the key to both clinical and financial success.

Table 1: Examples of MIPS Quality Measures for 2024

Process of Improving Clinical Documentation

Just as the financial impact and patient care outcomes of CDI differ between a hospital and a doctor’s office, so too does the process of improving clinical documentation. Regardless of location or size of the CDI team, clarification of clinical documentation in a medical chart is what drives a successful CDI program. Table 2 summarizes typical aspects of inpatient and outpatient CDI, but variations from these general statements is certainly possible.

Table 2: Comparison of Typical Inpatient Versus Outpatient CDI Process Components

Inpatient Process of CDI

The process of a CDI program in a hospital facility is concurrent, meaning a CDI specialist reviews documentation of an inpatient stay prior to discharge and can query the provider for updates to the patient’s chart. If there is nonspecific terminology, uncertain diagnoses, diagnostic test results not addressed, or diagnoses in a consult report not reiterated by the attending physician, the CDI specialist can immediately query the provider.

A query is a message to the provider to request clarification of clinical documentation. CDI specialists are knowledgeable of industry standards concerning proper and ethical queries. A query should not be suggestive of new information in a leading way, but rather should present facts available in the medical record that need clarification. Multiple choice queries should include the options of “clinically undetermined” or “not clinically significant.” In Scenario 1 of this article, a query to the provider was mentioned that resulted in clarification that the patient had acute respiratory failure with hypoxia and hypercapnia in addition to COPD with acute exacerbation. The query could have looked like this:

Are the lab results showing PO2 <55, PCO2 >50, and pH <7.35 as well as the 20 hours of ventilator assistance significant to the COPD exacerbation, significant to an as-yet undocumented diagnosis, clinical significance undetermined, or not significant?

The CDI nurse did not suggest the diagnosis of acute respiratory failure with hypoxia and hypercapnia, but, with the clinical facts, the query did prompt the provider to clarify a more specific diagnosis regarding the data available and treatment required. This was an acceptable nonleading query as it also gave the provider the option to state the significance was undetermined or the results and procedure were not significant at all.

Outpatient Process of CDI

The process of a CDI program in an outpatient setting is retrospective, meaning a CDI specialist reviews the medical record documentation after the office visit has occurred and the patient has left the face-to-face encounter. Sometimes retrospective CDI reviews can be weeks or even months after the date of service depending on the workflow of the CDI team. Communication to the provider in the outpatient setting is more along the lines of documentation improvement education and not a query as is seen in the inpatient facility.

In a provider’s office, the CDI specialist will review the medical record and identify issues like these:

• Medication is prescribed but the condition for which it is prescribed is not listed.

• The cause-and-effect relationship between two conditions was not documented.

• There is clinical evidence for a higher level of severity of a diagnosis than was reported.

Communicating the findings of these retrospective reviews needs careful wording just as a query in a concurrent review does. It is not acceptable for the CDI specialist to suggest a particular diagnosis, but, when used as an education opportunity, the CDI specialist can make the provider aware of the importance of using more specific terms and including the status of all coexisting conditions being monitored or treated that affect medical decision making. The CDI specialist can inform the provider about how this documentation affects coding.

An important proactive approach to outpatient CDI concerns recording social determinants of health (SDOH) with the intention of improving the health outcomes of patients. According to the World Health Organization (WHO), SDOH are the non-medical factors that influence health outcomes. In 2020, in the wake of the declaration of a global pandemic because of COVID-19, SDOH surged to the forefront of patient care. Not only have providers needed to adapt to conducting “office” visits via audio and/or video communication (telehealth visits) because of the pandemic, but assessing mental health, access to proper care, and other social determinants has been an important part of these discussions with patients. Even with the expiration of the COVID-19 Public Health Emergency on May 11, 2023, SDOH remains an important aspect to complete patient care.

CDI specialists can be a major help in identifying SDOH. There are assessment tools available to simplify documenting social parameters, such as PRAPARE^® (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences) from the National Association of Community Health Centers (NACHC). A CDI specialist can coordinate efforts such as having a patient fill out an SDOH assessment form before a visit, identifying areas of SDOH to be addressed by the provider, and including the form in the patient’s medical record. By working with the office staff in arranging social services ordered by the physician, the care of the patient can go beyond just the medical attention of diseases.

Implementing a Clinical Documentation Improvement Program

Accurate claim submission, favorable audit results, a healthy revenue cycle, and better health outcomes for the patient are all reasons to implement a CDI program. CDI can be challenging if all parties involved in implementing a CDI program (physicians, administrators, CDI specialists, and coding and billing staff) do not understand the purpose and process of CDI and how each role is vital.

5 Steps to Implement a Successful CDI Program

1. Analyze why the facility/practice needs a CDI program. Asking these questions is a great start:

• What is the claim denial rate? What are the top reasons for denials?

• What is the rate of admission to an acute care hospital for our patients with certain conditions (such as respiratory or diabetic complications)?

• Are we meeting compliance and regulatory standards? Has a government or payer audit identified deficiencies?

• Are we providing quality patient care to meet payer contract requirements? Are we meeting MIPS measures? Is our patient base susceptible to SDOH?

If the answer to any of these questions is less than favorable, then a CDI program may be warranted. Start with the desired outcomes of the program then build the processes to achieve those goals.

2. Decide how CDI reviews are selected. An inpatient CDI program may have EHR system alerts when a patient is admitted with certain complicated diagnoses. An outpatient program may have a policy to randomly select a sample of charts to review or generate reports of certain diagnoses to perform more targeted reviews. Set parameters of reviews based on the goals defined.

3. Establish clinical standards. To avoid overwhelming a provider with queries or education meetings, establish a decision-tree protocol of when a CDI specialist should query the provider to make the queries more meaningful. For example, just because the provider did not state a patient’s diabetes mellitus was controlled based on expected lab values does not mean the CDI specialist would query the provider. However, if the HbA1C was over 9 and the GFR was less than 60, a query to the provider concerning the specific status and any complications of the diabetes would be in order. Be consistent with both queries and education.

4. Review the reviews. The goal of periodic CDI compliance reviews is to evaluate not only the flow and results of the CDI program but also to determine whether the process follows ethical standards. Use an analysis rubric to identify areas of improvement, nonbeneficial activities, and the successful results of the program. Look for both the good and the bad practices when implementing a CDI program; meaningful outcomes should be the driving force of sustainability and growth.

5. Collaborate. The exchange of information between the CDI specialist and the medical coder — as well as the CDI specialist and the physician — is necessary to ensure the clinical documentation is not only thorough but also is accurately captured on a medical claim. Clinical documentation can be improved by having the CDI specialist lead educational meetings with the provider about clinical documentation improvement and with the coding team to improve code selection and application of coding guidelines.

Whether in an inpatient or outpatient setting, the success of a CDI program lies with the specialist. Only highly qualified professionals should be hired to perform CDI reviews. Nurses with coding experience and medical coders with CDI training are great candidates.

Last reviewed on Jan. 29, 2024, by the AAPC Thought Leadership Team