What is Clinical Documentation Improvement (CDI)?

isometric illustration of healthcare workers accessing data.

Today’s healthcare industry is governed largely by how accurately a provider’s care is detailed within the patient’s medical records. Payer reimbursement rates, public health data, disease tracking, and even physician report cards all hinge on properly capturing the exact scope and nature of both the patient’s diagnosis and services rendered by the provider, with failure to do so leading to lost profits for facilities and inferior health outcomes for the patient. Care teams must therefore work together to ensure that all services rendered are rightly articulated through the use of thorough reporting practices, making accurate clinical documentation improvement (CDI) a must. 

As the process of reviewing medical record documentation for completeness and accuracy, CDI offers a host of benefits to both patients and healthcare organizations. From fewer claims denials and higher reimbursement rates for facilities to fewer errors and higher quality of care for the patient, clinical documentation improvement can make revenue cycle management (RCM) workflows more consistent, relieve the burden of tedious documentation for clinicians, and paint a clearer picture of the scope of care provided to the patient overall. It requires careful adherence to best practices and the right tools to implement successfully — two of the most important being a CDI specialist and clinical documentation improvement software that integrates with existing electronic health record systems — but with the right strategy in place, organizations can boost profitability and patient care outcomes at the same time. 

What is CDI?

Clinical documentation improvement is the process of carefully scanning a patient’s medical records to make sure that their condition and all services rendered are articulated such that all claims can be accurately submitted to payers. CDI checks medical record documentation for completeness and accuracy, and it includes a review of factors such as the patient’s disease process, diagnostic findings, and considerations of what might be missing or need further clarification.

Despite the relatively wide definition, CDI rarely encompasses all parts of a patient’s medical records. For example, lab tests and consultations with specialists could comprise some data within a patient’s medical records, but CDI typically focuses on information entered by the provider at the time they visit the patient. Focusing on the coding data generated during or after the visit, a CDI program will usually check for the following factors within a patient’s health records: 

  • Consistency
  • Completeness
  • Accuracy
  • Precision
  • Timeliness
  • Legibility

By checking these parameters, CDI’s aim is twofold. It first identifies gaps in medical records that require further clarification to avoid a claims denial, and also locates services that had previously not been coded, and would therefore be left unbilled. In both cases, the CDI process more fully conveys the patient’s condition and treatment delivered, resulting in better outcomes for patients and organizations alike. 

Role of CDI Specialists in Healthcare Settings

The clinical documentation improvement process in healthcare is highly cross-disciplinary. It’s not feasible for all clinicians to familiarize themselves with the ins and outs of medical coding or for all medical coders to have in-depth knowledge of clinical conditions. That makes it necessary to find medical professionals with a mix of some clinical knowledge and some acquaintance with medical codes, or medical coding professionals with some prior knowledge of healthcare. 

This hybrid role is known as a clinical documentation specialist. They have a diverse knowledge set consisting of some medical training as well as medical coding, and they use it to bridge the gap between the two. CDI specialists are often RNs with a background in medical coding, but other disciplines such as respiratory therapists have also entered the field. The common denominator is that they must have training with medical codes.

Whatever their exact background may be, CDI specialists leverage their critical thinking skills to understand patient treatment processes while keeping medical coding requirements in mind. That allows them to query providers as to diagnoses and services rendered and create more thorough and billable clinical documentation in the process.

It’s important to note that a CDI specialist is expressly forbidden from making suggestions regarding patient care or medical findings, but their requests for clarification can generate a more thorough picture of the patient’s condition and what treatments were provided during the visit. This can also allow providers to bill for all the services they truly delivered, making healthcare organizations more profitable. 

Relevance of CDI in Ensuring Accurate Patient Records

Clinical Documentation Improvement(CDI) plays a key role in ensuring that all patient records are accurate — and that has a profound impact on both facilities and the patient.
From the facility’s perspective, errors in patient records are especially problematic not only because of their consequences but also because of the difficulty in keeping them accurate. Medical records often contain a great deal of unstructured data, which is information that must be translated into a quantifiable format before it can be used. Some examples of unstructured data include:

  • Test results
  • Imaging
  • Clinician referrals
  • Handwritten notes
  • Faxes and scanned documents  

Such unstructured data can be difficult to capture correctly, and failure do to so could result in claims denials, incorrect billing, and even costly compliance violations. Clinical documentation improvement programs can help capture and format the unstructured data found in medical records, thereby improving their accuracy and avoiding the costs of an error. 

From the patient’s perspective, inaccurate patient records could result in errors in treatment and lower their quality of care. CDI can help catch discrepancies within medical records to give a clearer picture of patients’ needs, and it can also be used to evaluate environmental factors that could impact their health. 

For example, many clinical documentation improvement solutions incorporate social determinants of health (SDOH) into their technology, allowing CDI specialists to inquire regarding external conditions that may need to be addressed. Such factors may range from adequate shelter and food supply to a living arrangement free from domestic abuse. By including SDOH in their considerations, CDI specialists may identify a patient’s need for additional services, contributing to a more holistic approach to patient health. 

Key Components of Effective Clinical Documentation Improvement

An efficient CDI program has several moving parts. Some of the primary components driving a successful CDI system are:

Education

Managers must train all team members on how they can develop more comprehensive medical records and provide education on the requirements of their documentation process. This may include an overview of what CDI specialists look for as they examine medical records, as well as giving some examples of when additional documentation is needed.  

SOFTWARE

Your clinical documentation improvement software should be compatible with your existing electronic health records system. It should also be powered by AI capabilities that allow you to turn unstructured data into actionable medical insights, and then convert those insights into more thorough documentation and accurate medical codes — the kind that payers will approve.

Personnel

At the end of the day, a CDI system is only as effective as the staff members themselves. Your CDI specialist should work closely with clinicians and coders to make sure that all services rendered are captured and that the patient’s condition is rightly conveyed. For CDI to be a success, the entire care team must be on board.  

The required investment in education, software, and staffing may seem daunting at first, but the payoff is more than worthwhile. More complete documentation means fewer denials, higher reimbursement rates, and less time spent on documentation, as well as higher quality care for the patient. This leads to even greater revenue as reimbursement models continue to shift toward consumer-based care, creating a virtuous cycle where facilities are even more profitable. 

Process for Improving Clinical Documentation

The exact inner workings of the CDI medical process can vary based on a number of factors, but the main one is whether the facility operates in an inpatient or outpatient context. This can impact how data is collected, when providers are queried, when the claim is submitted, and more. The main differences between inpatient and outpatient CDI processes are:

  • CDI specialists: skill level
  • Review time
  • Communication method
  • Claim submission time
  • Provider response time
Here’s a look at the differences between the two.

INPATIENT

In an inpatient setting, the CDI process is carried out throughout the time of the patient’s stay. That means an inpatient CDI framework might have the following components:
  • CDI specialist skill level – A CDI specialist would likely be an RN or other medical professional with some training in medical codes. Review time – All CDI reviews would be done concurrently, while the patient is in the facility.
  • Communication method – A CDI specialist would communicate directly with providers, querying them as needed. Claim submission time – Claims would be submitted after a CDI specialist’s review.
  • Provider response time – The provider would revise or give additional documentation during the patient’s stay.
Perhaps most importantly, an inpatient CDI process requires ongoing revision and monitoring, evolving as the patient’s care journey progresses.

OUTPATIENT

In an outpatient setting, the CDI process occurs primarily after the visit. Some of the differences are:
  • CDI specialist skill level – Outpatient CDI specialists are usually medical coders who have received CDI training.
  • Review time – Documentation is reviewed after the visit is over.
  • Communication method – CDI specialists educate providers on how to provide more effective documentation in the future, instead of requesting clarification during admission.
  • Claim submission time – Claims are submitted prior to a CDI specialist’s review, with spot checks conducted periodically.
  • Provider response time –  Providers may revise or give additional documentation at the next visit, rather than during admission.
While an inpatient CDI specialist’s work may be to inquire as to ongoing treatments and services, outpatient CDI specialists may ask questions regarding the cause-and-effect relationship between comorbidities or why a medication was prescribed without the diagnosis being listed. Both are essential for a healthcare organization’s profitability, and both can improve a patient’s quality of care.

Steps To Implement a Successful CDI Program

Whether it’s for an inpatient or outpatient setting, implementing a successful CDI program requires careful planning and execution. The exact tactics will vary with each organization, but these steps are a good place to start:

  1. Evaluate the “why.” What do you hope to accomplish with your CDI initiative? Facilities struggling with an unusually high claims denial rate may have different objectives than those seeking to improve their data collection, so organizations should consider their goals for the program and draft their policies accordingly.
  2. Create a review system. It’s unlikely that organizations will be able to review every medical record, so develop criteria for when CDI should take place. Some inpatient CDI systems review only those cases that are flagged as being especially complex, while outpatient CDI specialists may conduct spot checks or take random samples to monitor their facilities’ broader documentation practices.
  3. Establish a standard. Providers face too great a workload to be queried every time a question arises. Establish a protocol determining when CDI specialists should seek clarification so that providers won’t be overwhelmed.
  4. Review the process. The goal of a CDI program should be to improve an organization’s operability and offer positive patient health outcomes. Create tools such as analysis rubrics and metrics to identify where your CDI program is thriving, as well as opportunities for growth.
As with many healthcare strategies, collaboration is especially important to your CDI program’s success. Clinicians, CDI specialists, and medical coders must all be on the same page and consistently review provider and physician practices to see how their documentation can improve. By communicating early and often regarding issues that may arise, a CDI team can make sure that the program remains a success, but failure to collaborate may cause the system to fall short of its goals.

Best Practices for Comprehensive Documentation

Several best practices exist to help organizations launch an effective CDI program. Some of these are as simple as facilitating communication between all team members and providing adequate training, while others require a more technical approach such as choosing the right software and conducting regular quality checks. Follow these best practices to make your CDI initiative a success.  

Implement Robust Documentation Training Programs

Education is essential for a quality CDI program. Managers should regularly train all team members on leading CDI best practices and should develop rigorous training programs according to industry standards. 

IoT is also used in a variety of settings, including the medical industry. Home monitoring systems may be able to communicate medical information to healthcare providers. Those providers may then be able to connect to patients via patient portals and make adjustments to treatment plans based on the feedback they’re receiving. 

The Association of Clinical Documentation Integrity Specialists (ACDIS) is the leading body concerning CDI processes and can equip healthcare organizations with multiple resources to create an effective CDI program. Among these are a wide range of educational tools that organizations can use to help train team members on proper clinical documentation practices, and prospective CDI specialists may obtain their certification for both inpatient and outpatient sides too.

Leverage Technology for Streamlining Documentation Processes

CDI specialists must be furnished with the right tools if they hope to evaluate patient records effectively. Organizations should seek out clinical documentation improvement software with the capabilities their facility needs. 

Not only should their CDI software integrate with their existing EHR systems, but the solution they choose should be able to process the unstructured data so common to patient medical records. Clinical documentation improvement solutions featuring AI/ML technologies are well-suited to this task, as they can efficiently parse faxes and scanned documents and format them into the quantifiable data that CDI specialists need for circumspect medical coding. 

Ensure Collaboration Between CDI Specialists and Healthcare Providers

If CDI specialists are unable to communicate with healthcare providers, they won’t be able to request clarification on gaps in medical records or make recommendations for future improvement. That makes collaboration a must for CDI to be a success, so organizations should find ways to allocate time for the two to communicate without hindering the provider’s already busy schedule.

Conduct Regular Audits and Quality Checks

CDI specialists may not be able to review every medical record, but they should still conduct quality checks. The exact number of audits may vary with each institution, but they should review enough medical records that they can identify patterns in existing documentation practices and find opportunities for growth.

Benefits of Clinical Documentation Improvement

CDI processes can improve an organization’s operability and profitability, as well as elevate a patient’s quality of care. It can achieve these benefits in several ways, and while its exact use may vary according to the purposes of each facility, the following CDI benefits are most common. 

Improved Patient Care and Safety

Patient care should always be a top priority for healthcare organizations, and CDI helps improve it in several ways. 

First, by closely inspecting a patient’s health records, CDI specialists can unveil discrepancies and thereby reduce errors in their care. For instance, patients currently receiving a certain medication may be unable to take other medications due to drug interactions, and if this were overlooked by a provider, a CDI specialist could detect it. Also, while they’re unable to make recommendations regarding diagnoses, the clarifications that CDI specialists request could bring other factors to mind, leading to a more circumspect picture of the patient’s health. 

Increased Reimbursement and Revenue

A key benefit that CDI processes offer to healthcare organizations is the increased reimbursement and revenue opportunities that they provide. 

By ensuring that all services rendered are accurately captured, CDI teams reduce the likelihood that a claim will be denied. More approved claims mean more revenue, but CDI can elevate reimbursement rates in other ways as well. For instance, those participating in Medicare’s Merit-based Incentive Payment System (MIPS) can implement CDI to improve quality care metrics, thereby further increasing their reimbursement rates.

Enhanced Communication Among Healthcare Providers

Sometimes discrepancies in medical records arise due to miscommunications between healthcare providers. By analyzing a patient’s past and current treatment plans, a CDI specialist can detect possible miscommunications to help providers reach a clearer path forward, which further elevates patient care. 

Mitigation of Legal and Compliance Risks

Another benefit of CDI is the added layer of protection it offers for providers when they face legal situations. Lawsuits are possible no matter how hard providers work to deliver quality care, and having another set of eyes on a patient’s medical records further reduces the probability of litigation, as well as helping ensure compliance. 

Resources and Tools for CDI Implementation

Whether you’re looking to learn the basics of what clinical documentation improvement is or are seeking to implement a CDI program of your own, many resources exist to help you develop an initiative that suits your goals. The ACDIS is an excellent place to start, and a quality CDI software provider can also help furnish you with the technological tools you’ll need.

How Clarity Clinical Documentation Can Help

If healthcare organizations hope to receive maximum reimbursement for optimal profitability, it’s essential that their patients’ medical records be correct, comprehensive, and clear. Such accurate documentation not only reduces the likelihood of claims denials and increases revenue but results in better patient outcomes too. By addressing SDOH factors within the patient population and improving the collection of public health data for research purposes, CDI can contribute to a healthier world overall, making it a win-win for each party involved.

We at Consensus believe in leveraging clinical documentation to improve healthcare processes from provider to patient. That’s why we developed Clarity, our intelligent CDI software solution. Its cutting-edge natural language processing (NLP) technology extracts unstructured data from electronic health records, reducing the likelihood of errors and unveiling actionable data that can improve patient health outcomes. 

Clarity’s data extraction capabilities allow your CDI specialist to properly code all services rendered in both inpatient and outpatient settings, improving your facility’s processes and profits. Sign up for Clarity today, and let help streamline your CDI efforts.