Why and How to Build a Successful Clinical Documentation Improvement (CDI) Program

This article is the first of a three-part series by AGS Health regarding the value of clinical documentation improvement (CDI). We begin by sharing why and how healthcare organizations should build a CDI program.

As the first step toward maintaining accurate health data, CDI ensures that the events of the patient encounter are captured accurately and that the electronic health record (EHR) properly reflects provided services. Without CDI, a myriad of issues can impact various factors, including revenue, reimbursements, compliance, patient experience, and more.

The adoption of CDI programs drives tangible, measurable results in improved patient care and efficiencies in the revenue cycle. A survey by Black Book found that 88 percent of hospitals have documented quality improvements and increases in case mix index (CMI) within six months of launching a CDI initiative, while more than 90 percent of hospitals with 150 beds or more – all of which outsourced their CDI programs – reported CDI-related increases in appropriate income and reimbursements by more than $2.1 million.

With the ongoing shift to value-based care, hospital and physician financial executives are continuing to explore new ways to use data analytics to support reimbursement. Evolving CDI initiatives are a natural extension in managing the transition from volume to value, which requires accurate and concise documentation of a patient’s health and conditions supported by evidence. CDI has emerged as a primary pillar of any value-based strategy – particularly when it is supported by a deep understanding of and ability to demonstrate the ROI it delivers.

Building a successful CDI program starts with identifying the organizational pain points that could be eliminated with improved documentation quality. These may include:

• Potential Financial Impacts (e.g., Denial Rates and Quality or Outcome Measures)
• CC/MCC (Comorbidity or Complication/Major Complication or Comorbidity) Capture Rates
• SOI/ROM (Severity of Illness/Risk of Mortality) Capture Rates
• Over or Under-Coding and Severity Levels
• CMI (Case Mix Index) Variances

After identifying the primary pain points, one model for implementing a highly effective and successful CDI program is the centralized systems/decentralized specialties approach. It enables the systems, processes, and resources shared broadly across specialties to be managed by one centralized governing body while the documentation produced within each respective specialty remains decentralized. This ensures the documentation is reviewed by true experts in each area rather than by CDI specialists who do not have – nor can realistically be expected to develop – the level of expertise required to be optimally effective within each individual specialty.

The centralized systems/decentralized specialties are peer-to-peer, helping gain acceptance of CDI while still allowing for a high degree of standardization of processes and procedures. It can also lower costs related to CDI by opening the door to near-shore, off-shore, and domestic outsourcing of standardized tasks.