Clinical Documentation Improvement (CDI): Definition and Explanation

Clinical Documentation Improvement (CDI) is a process in healthcare organizations aimed at enhancing the accuracy, clarity, and completeness of patient medical records. This process involves a collaborative effort between healthcare providers, such as physicians and nurses, and CDI specialists to ensure that the medical documentation fully captures the patient’s clinical status, the scope of services rendered, and the diagnostic and therapeutic outcomes. Effective CDI programs facilitate the accurate representation of a patient’s health status in the medical record, which supports quality patient care, accurate reporting, compliance with regulations, and optimized reimbursement.

The primary goals of CDI are to improve care quality, ensure appropriate clinical documentation, enhance coding accuracy, and secure appropriate revenue for the healthcare services provided. By improving documentation, CDI helps in reducing ambiguities and errors in patient records, thereby enhancing the reliability of health information used for patient care, billing, and analytics.

Developing and Evaluating a Physician Query for Resolving Data and Coding Discrepancy

Scenario: A patient was admitted with chest pain and was found to have a myocardial infarction (MI) during the stay. However, the initial documentation in the electronic health record (EHR) only mentions “chest pain” without specifying the MI.

Physician Query:
Subject: Clarification Needed for Diagnosis Documentation

Message: Dear Dr. Smith,

During a review of the medical record for Mr. John Doe, admitted on [date], I noted that the diagnosis documented at admission was ‘chest pain’. However, subsequent test results confirmed a myocardial infarction. To accurately capture the patient’s clinical condition and ensure appropriate DRG assignment, could you please clarify if the myocardial infarction was present on admission? Additionally, please document any specific type of MI (e.g., STEMI or NSTEMI) and related complications, if applicable.

Thank you for your attention to this matter.

Evaluation: This query is effective as it:

Specifies the Discrepancy: It clearly identifies the mismatch between the initial and subsequent diagnoses.
Requests Specific Information: It asks for precise details (type of MI, complications) that impact coding and DRG assignment.
Supports Compliance and Reimbursement: By urging the physician to specify details about the MI, the query supports accurate coding, which in turn influences compliance with healthcare reporting standards and determines appropriate reimbursement levels.

Such queries not only resolve discrepancies but also educate physicians about the importance of detailed and specific documentation, which can improve overall documentation practices over time.