As per the Association of Clinical Documentation Integrity Specialists (ACDIS), data from a survey conducted in 2016 indicated that only 10% of hospitals had an outpatient Clinical Documentation Integrity (CDI) program. Fast-forward five years to 2021 and that number increased to 24% (1).

CDI or Clinical Documentation Integrity, is a process aimed at ensuring that the documentation in a patient’s medical record accurately reflects the patient’s condition and the care they receive. It helps ensure better patient outcomes, data quality, and accurate reimbursement. According to the American Academy of Pain Medicine, CDI programs were started by hospitals in response to the use of Diagnosis Related Groups (DRGs) for reimbursement. Physicians have also been asked to provide additional documentation to support specific ICD codes for enhanced data collection and hospital reimbursement (4).

Benefits of Implementing CDI

• Improved patient care: Accurate and complete documentation ensures that healthcare providers have the information they need to make informed decisions about patient care.
• Better communication: Clear and concise documentation helps to ensure that all healthcare providers are on the same page regarding a patient’s health status and treatment plan.
• Accurate reimbursement: Accurate documentation can help ensure appropriate reimbursement for services provided and reduce the risk of audits or denied claims.
• Better data for research and population health management: Accurate documentation ensures that data used for research and population health management is reliable and representative of the patient population. (2)

The Role of CDI in Risk Adjustment

CDI programs have become increasingly important in risk adjustment, where healthcare payers adjust payments based on the health status of their members (1). The accurate documentation provided by CDI professionals ensures fair payments and effective population health management.

Integrating CDI in the Hierarchical Condition Categories (HCC) System

One of the models used in risk adjustment is the Hierarchical Condition Categories (HCC) system, which uses diagnosis codes to predict the expected cost of care for a patient. HCCs categorize diagnoses into condition groups, with each group assigned a weight based on the expected cost of care for that group. The more severe the condition group, the higher the weight assigned, resulting in higher payments for healthcare providers (3).

CDI professionals play a critical role in HCC risk adjustment by ensuring accurate and complete documentation of a patient’s health status. They review medical records to identify documentation gaps and work with physicians and other healthcare professionals to ensure that the medical record accurately reflects a patient’s health status (1). By improving the quality of documentation, CDI professionals help ensure that HCC models accurately capture a patient’s risk and that healthcare payers provide fair compensation to healthcare providers (3).

Here’s an example:

Suppose a healthcare payer has a member who has been diagnosed with diabetes and requires regular treatment and care. The healthcare payer wants to ensure that the member receives appropriate care and treatment and that the healthcare provider is appropriately compensated for the services rendered.

The healthcare payer’s risk adjustment model uses Hierarchical Condition Categories (HCCs) to adjust payments based on the member’s health status. A CDI professional working for the healthcare provider identifies gaps in the documentation related to the member’s diabetes diagnosis and treatment. The CDI professional works with the healthcare provider’s coding staff to ensure that the medical record accurately reflects documentation of the member’s blood sugar levels, medications prescribed, and any other relevant information. This documentation helps the healthcare provider accurately code the services provided, which can lead to fair compensation from the healthcare payer.

As a result of the CDI professional’s work, the healthcare payer has accurate data on the member’s health status, which can inform decisions about future care and treatment. Additionally, the healthcare provider receives fair compensation for the services rendered, enabling them to continue providing quality care to their patients.

A successful CDI program in risk adjustment requires collaboration between CDI professionals, coding staff, physicians, and other healthcare professionals. CDI professionals must be knowledgeable about the data needs of risk adjustment models and be able to identify documentation gaps that impact a patient’s health status. They must also ensure that documentation is accurate, consistent, and supports the correct ICD codes (1).

CDI plays a critical role in risk adjustment, ensuring that healthcare payers have accurate data to make informed decisions about patient care and payments. CDI professionals must work collaboratively with other healthcare professionals to identify documentation gaps and ensure accurate and complete documentation to support risk adjustment models (1).

Today, CDI programs are more robust and have the ability to collect and track data. While traditionally a hospital-based program, CDI is now recognized as important in physician practices as well. The completeness, consistency, organization, and accuracy of the medical record are the key components of CDI, reflecting the physician’s clinical judgment and medical decision-making.

References:

1. Risk-based CDI: A holistic approach to record review. (n.d.). Retrieved May 2, 2023, from https://acdis.org/sites/acdis/files/resources/CR-5311_ACDIS%20Risk%20Adjusted%20CDI_PP_Final.pdf

2. EHRIntelligence. (2023, January 19). What are the benefits of clinical documentation improvement (CDI)? EHRIntelligence. Retrieved May 2, 2023, from https://ehrintelligence.com/features/what-are-the-benefits-of-clinical-documentation-improvement-cdi

3. Radio recap: The role of CDI in risk-adjustment. ACDIS. (n.d.). Retrieved May 2, 2023, from https://acdis.org/articles/radio-recap-role-cdi-risk-adjustment

4. Hill, E. (2018, December 18). What is CDI and how does it impact you? AAPM. Retrieved May 2, 2023, from https://painmed.org/what-is-cdi-and-how-does-it-impact-you/