Acute Coding Review 

Clinical Documentation Integrity (CDI)


Clinical Documentation Integrity (CDI) – Inpatient and Outpatient


Having an established Clinical Documentation Integrity (CDI) program positively affects revenue and improves quality measures for hospitals and physicians. That's why HIA has developed its CDI package. Our clients see a reduction in claims denials and an improvement in the appeals process with better documentation. 

Clinical documentation must be clear, consistent, complete, reliable, legible, precise and timely. These characteristics will make certain that a patient’s clinical status and the level and type of care provided is accurate. In today’s complex healthcare environment, clinical documentation and coding impact quality reporting, reimbursement, public health data and ultimately your patient’s current and future care. It is imperative that your CDI program is effective.

Here's just a peek at what we can offer on-demand iNucleus, HIA's secure client portal:

  • Listing of all accounts where CDI was involved on the encounter with or without potential CDI query opportunities
  • Consolidated summary of CDI accuracy rates
  • Detailed listing of individual CDI accuracy breakdown
  • Overview of CDI opportunities with potential query opportunity accuracy rates
  • Missed query opportunities or invalid queries, if any
CDI Summary Worksheet Dashboard 2

Our comprehensive approach

HIA's CDI review services ensure the ICD-10-CM/PCS and CPT-4 codes assigned appropriately reflect the clinical indicators, diagnosis and procedures documented. Educational opportunities will be identified for your CDI staff, providers and other stakeholders that will facilitate overall improvement.

Atom Audit - Medical Coding Audit Platform from Health Information Associates



Following a comprehensive CDI review, HIA offers a multi-pronged approach to educating the relevant stakeholders in your organization. It all starts with an executive summation conference to discuss overall findings. This is followed by an educational session involving your coding team, CDI specialists, providers and any others from your organization that you wish to include. In order to minimize interruption to daily production, these sessions are usually one to two hours in duration and focus heavily on common trends and opportunities. Individual educational needs are met with a coder specific action plan drawn from review findings and supported by HIA's proprietary learning management system. All facets offer opportunities to gain CEU's and represent a comprehensive solution to meet educational needs. 
Writing Effective Physician Queries Free Course

Free Course

Writing Effective Physician Queries

HIAlearn courses are designed to cover topic areas that impact coding, have been the frequent source of errors by CDI Specialists and coders and usually affect DRG assignments. In this course, we will give you a brief historical background of queries and when they should be written. Coders will learn what constitutes a leading query and how to avoid one.

Settings we serve


Here’s a brief, but by no means exhaustive, list of the settings we serve most often:  


  • Short-term acute  
  • Long-term Acute  
  • General med/surg  
  • Pediatric  
  • Academic/teaching  
Other Solutions and Services 


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