WHAT IS A CLINICAL DOCUMENTATIONIMPROVEMENT PROGRAM?By Richard Pinson, MD, FACP

Medical record documentation determines the reimburse-ment paid to physicians and hospitals, but so much more

than money is at stake. After the documentation is translatedinto the alpha-numeric codes submitted in claims, the data areanalyzed to generate results on quality and clinical outcomemeasures, in addition to payments.

For example, codes reflecting severity of illness and risk ofmortality are used to risk-adjust data in order to avoid penaliz-ing clinicians who care for sicker patients. This levels the play-ing field for all clinicians. Therefore, clinician documentationmust translate into precise codes that will fully reflect illnessseverity and mortality risk, intensity of services provided, andresources expended in caring for patients.

However, since coding rules and terminology differ fromcommon clinical language, there is a risk that the clinical reali-ty will get lost in translation. This is where clinical documenta-tion improvement (CDI) programs come in.

A CDI program is a comprehensive, multi-disciplinary, hospital-wide effort to incorporate the terminology needed toaccurately translate a patient’s condition into precise codes. Today,more than 80% of U.S. acute care hospitals have established CDIprograms, the objectives of which are listed in Table 1.

Clinicians play the most important part in CDI, since theyare intimately familiar with the patient and the conditions beingtreated. Their documentation drives and controls everything thathappens subsequently. Clinician CDI participation has 3 compo-nents: awareness, competence, and collaboration (see Table 2).

CODING CORNER

Table 1. Objectives of clinical documentation improvement programs■ Accurately reflect each patient’s severity of illness and

complexity of care

■ Optimize quality and outcome performance measures

■ Assure appropriate reimbursement for services provided

■ Facilitate timely claim submission

■ Reduce denials by third-party payers and other external review organizations, including recovery audit contractors

Table 2. Components of physician participation in clinical documentationimprovement programsAwareness

■ Participate in clinical documentation improvement(CDI) educational activities

■ Understand impact and objectives of CDI

■ Ask questions and contact clinical documentation specialist (CDS) if needed

■ Request performance metrics

Competence

■ Give proactive attention to common documentationchallenges

■ Use authoritative diagnostic standards and criteria

■ Apply reasoned clinical judgment and knowledge

■ Restate all pertinent diagnoses in discharge summary

Collaboration

■ View the CDI team as an ally

■ Read all queries, reply promptly, document precisely

■ Invite CDS to conferences

■ Teach colleagues

The key players on a CDI team are clinicians, clinical doc-umentation specialists (CDS), and inpatient coders. Othermembers include those in nutrition service, wound care, caremanagement, and the lab. Clinicians in this case include anyhealth care professional licensed and credentialed to diagnoseand treat patients, including doctors of medicine (MD), doctorsof osteopathic medicine (DO), doctors of podiatric medicine(DPM), residents, nurse practioners, physician assistants, nurseanesthetists, and others.

12 ACP Hospitalist November 2014

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