Clinical Documentation Integrity (CDI) ensures that patient records accurately reflect diagnoses, treatment, and resource utilization—forming the foundation for compliant coding and reporting. Clinical Documentation Integrity Specialists (CDIS) play a key role in this process by reviewing documentation, validating diagnoses with clinical indicators, and working with providers to clarify incomplete or unclear records. Their work directly impacts coding accuracy, quality metrics, audit outcomes, and reimbursement. In this article, we outline the purpose of CDI, the responsibilities of CDI specialists, and the processes—such as concurrent review, retrospective review, and compliant querying—that support accurate and defensible medical coding.
Cari Greenwood, RHIA, CCS, CPC, Senior Content Strategist, contributed to this article.
The goal of CDI is to assemble an accurate representation of the patients diagnoses that reflects the associated diagnostic criteria, treatment, and resources used during the hospital stay. Collecting this data helps to accurately capture severity of illness, risk of mortality, and medical necessity which assists the quality and compliance department to meet regulatory requirements.
Clinical documentation integrity specialists work to:
The majority of CDIS are registered nurses who have formal education in medical terminology, human anatomy and physiology, pathology/disease process, and pharmacology. However, coding professionals or other health information professionals or clinicians with the necessary qualifications may also fill the role of CDIS. Those interested in working as a CDIS can verify their skills by obtaining one of the following certifications.
Certified Documentation Integrity Practitioner (CDIP)
Offered through AHIMA. Requirements are listed on the AHIMA website, https://www.ahima.org/certification-careers/certifications-overview/cdip/
Clinical documentation improvement specialists use a process of record review combined with querying providers to clinically validate the diagnoses documented in the medical record.
Retrospective review of the medical record takes place after the patient has been discharged to ensure documented diagnoses are supported by clinical diagnostics and treatment prior to billing.
Concurrent review takes place while the patient is hospitalized. Reviewing the medical record concurrently gives CDIS an opportunity to work with members of the healthcare team while they are actively caring for the patient. Reviewing provider’s documentation and diagnostic and procedural findings in real time allows open communication with physicians about a patients disease process. This provides an opportunity to communicate with physicians via a query to clarify vague, incomplete, or missing diagnosis so that it may be revised prior to discharge.
CDIS use queries as a tool to communicate with physician’s and other providers to establish or confirm diagnoses and otherwise clarify concerns about documentation. The American Health Information Management Association (AHIMA) and Association of Clinical Documentation Integrity Specialists (ACDIS) Practice Brief, Guidelines for Achieving a Compliant Query Practice is a resource for coding and CDI professionals in inpatient and outpatient healthcare settings. It provides guidance in creating queries that are compliant; clinically supported with relevant clinical indicators and treatment without leading or suggesting a specific diagnosis is warranted.
To learn more about ACDIS/AHIMA guidelines for a compliant query, visit: ACDIS AHIMA Guidelines for a Compliant Query 2022_addendum2023.pdf
Clinical validation of a diagnosis comes through support provided by clinical indicators documented in the medical record. Clinical indicators are relevant, standardized and measurable elements metrics used to assess and monitor the patient’s diagnostic status and treatment.
Clinical indicators used to validate diagnoses can be found from documentation throughout the entirety of the medical record. Types of documentation that CDIS review and some of the clinical indicators they look for in that type of note include:
More information about clinical indicators can be found in the ACIDS practice brief Guidelines for Achieving a Compliant Query Practice.
CDIS act as a bridge between physicians and coders to ensure the clinical picture accurately reflects the diagnoses the patient is being treated for. The partnership helps translate diagnoses and procedures into coding information allowing for proper capture of severity of illness, risk of mortality, and the resources used during a hospital stay, all of which contribute to proper reimbursement. The goal is ensuring proper physician documentation with up-to-date clinical indicators are available to facilitate accurate coding before submitting a claim. Submission of accurate claims reduces improper payment and risk of denial.
For practical examples of the work performed by CDIS, see the HIAcode Blog post The Importance of CDI Review Notes.
References
For the past 30 years, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.