Are CDI Programs Operating at the Top of Their Game?

The clinical documentation integrity (CDI) profession began its heyday in 2008, with the advent of the Medicare Severity Diagnosis-Related Group (MS-DRG) system that built and expanded upon the simpler system consisting of DRGs with complications and comorbidities (CCs) or major CCs (MCCs) and those without. 

Consulting companies recognized the opportunity to develop and market CDI programs to chief financial officers, promising marked improvement in CC/MCC capture and case mix index (CMI).

As time progressed, CDI programs continued to evolve, with the introduction of software programs that enhanced the efficiency and overall effectiveness of the overall CDI process by “prioritizing” charts for review that were identified as having a strong likelihood of “improvement” in documentation – translating to a higher-weighted MS-DRG with the capture of a CC or MCC.

More recently, CDI software has evolved wherein artificial intelligence/natural language processing (AI/NLP) is being embedded into the software that points out and provides “nudges:” suggested diagnoses for the physician to consider in real time while charting in the electronic health record. There are even CDI programs that can automate queries without active intervention, issuing them based on available clinical information within the record. There is a definite need for CDI software in all CDI programs, provided that the structure and processes of the programs are fine-tuned and operate smoothly, with the use of a multidisciplinary approach that involves all relevant stakeholders.

An Effective CDI Program

There are 10 key required components of an effective CDI program that provide the structured framework for long-term success in facilitating complete and accurate physician documentation. An effective CDI program can be measured and judged by the ability to achieve complete and accurate physician documentation that is sustainable over time, with the alleviation of many self-inflicted payor denials. Hospitals and health systems are under siege by payors that are denying claims at an alarming rate. According to Kodiak Solution’s analysis using their Revenue Cycle Analytics, the final denial rate on inpatient claims, as measured by the dollar value of claims denied as a percentage of the total dollar value of inpatient claims analyzed in the report, increased by 51 percent from 2021 to 2023. The increase in initial denials of inpatient claims by insurers for prior authorization and precertification errors mirrors the increase in the final inpatient denial rate: initial denials for these errors have risen from 1.73 percent of the value of inpatient claims in 2021 to 2.18 percent in 2023, a 26-percent increase. The increase in final inpatient claim denials drained $1.2 billion in revenue that hospitals and health systems rely on to provide care to their communities.

A highly organized, well-structured program designed to facilitate better physician documentation that adequately communicates patient care tracks an emergency department visit to the decision to hospitalize the patient, the initial hospitalization of the patient, progress of the patient as described in the progress notes, and the clinical stability of the patient at time of discharge, with a discharge summary that meets the requirements of the Joint Commission, at a minimum. Measuring the success of any CDI program can be quantified using (but not limited to) the number and dollar value of medical necessity and clinical validation denials over time and the successful overturn of these same denials over time. All these measures should be trending lower, moving forward in tandem with CDI operations.

The Top Ten Requirements of an Effective CDI Program

Here is a summary of the core components essential for a CDI program that aligns well with the CDI profession’s ability to meet its goals and objectives in achieving maintainable “integrity” of the record:

1. Physician Engagement and Collaboration:
   • Foster strong, collaborative relationships between physicians and CDI Specialists (CDISs).
   • Ensure that physicians are actively involved in the CDI process through regular feedback and training.
2. Physician Documentation Training:
   • Implement targeted training programs to educate physicians on best practices for documentation.
   • Use CDI specialists to guide and support physicians in improving documentation quality.
3. Multidisciplinary Team Approach:
   • Create a cohesive team, including physicians, physician advisors, case management, utilization review, coders, and denials and appeals experts.
   • Promote regular communication and collaboration among team members to align goals and strategies.
4. Detailed Documentation Review:
   • Conduct thorough and regular reviews of clinical documentation to identify gaps and areas for improvement.
   • Ensure that reviews are conducted in a manner that supports accurate coding and reflects the complexity of patient care.
5. Comprehensive Feedback Mechanisms:
   • Establish clear feedback loops whereby physicians receive actionable insights and recommendations based on documentation reviews.
   • Facilitate ongoing dialogue between CDI specialists and physicians to address documentation issues and track improvements.
6. Data-Driven Insights:
   • Utilize data and analytics to monitor documentation trends, identify common issues, and measure the impact of CDI interventions.
   • Use data to drive targeted improvements and inform decision-making processes.
7. Coding Accuracy and Compliance:
   • Ensure that coders are well-integrated into the CDI process and that coding reflects the clinical documentation accurately.
   • Regularly audit coding practices to maintain compliance with regulations and coding standards.
8. Effective Use of Technology:
   • While acknowledging technology’s role, prioritize its use in a supportive capacity, rather than as a standalone solution.
   • Integrate technology where it enhances the CDI process, such as through electronic health records (EHRs) and documentation tools.
9. Continuous Education and Knowledge Sharing:
   • Promote ongoing education and professional development for all members of the CDI team.
   • Share knowledge and best practices across the organization to foster a culture of continuous improvement.
10. Sustainability and Adaptability:
    • Develop strategies to ensure that the CDI program remains sustainable and adaptable to changes in regulations, clinical practices, and organizational needs.
    • Regularly evaluate and refine the CDI program to maintain effectiveness and relevance.

The “Right Approach” to CDI

The right approach to a meaningful CDI program that operates at the top of its game and consistently facilitates better documentation must emphasize the importance of collaboration, education, and balanced use of technology, aligning with the principle that physician-led improvements, supported by CDI specialists, are key to achieving documentation excellence.

Given the advancement of AI, ambient clinical intelligence tools, and other AI-driven tools, there will soon be less opportunity for CDI as currently exists in the marketplace. Change in present-day CDI practices is inevitable; pivoting away from a primary focus on diagnosis capture to an approach that incorporates the top 10 requirements of an effective CDI program will drive the achievement of far better and sustainable documentation.

Physicians will become more engaged, willing participants in any CDI program where they are at the center of attention, along with the patient. The true potential of CDI can be achieved, provided that the profession operates at the top of its ability.