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Begin Your Own CDI Program

Capture conditions with clear, concise documentation to increase reimbursement and decrease risks.

By Karen Stanley, MBA, RN
A clinical documentation improvement (CDI) program is a great way to ensure your facility is capturing all relevant details of a patient/provider encounter. This, in turn, boosts clinical and financial outcomes.
CDI programs began in the 1990s. Most were pilot projects to assess how such programs affect physician documentation. They have become more common since 2007, when the Centers for Medicare & Medicaid Services (CMS) implemented Medicare severity-diagnosis related groups (MS-DRGs). Accurate DRG reporting increases Medicare reimbursement and reduces compliance risks. CDI programs optimize DRGs by capturing conditions through clear, concise documentation.

Use Queries to Prompt Complete Documentation

Queries are an essential component of any CDI program. A query is a communication and education tool that prompts physicians to provide greater detail about under-reported conditions found in the medical record. For instance, if pneumonia is the primary diagnosis but the type is not noted, the query provides options to describe the condition as “viral,” “bacterial,” “community acquired,” or “hospital acquired.”


Clarification for specificity of a diagnosis-patient admitted with productive cough, yellow sputum x 3 days-CXR reveals right lower lobe infiltrates/Dx: Pneumonia:Zosyn 3.375 g IV qd ordered/sputum cx sent;


Can the origin/etiology of the patient’s pneumonia be further specified? Please type or dictate your response.

The resulting documentation better reflects co-morbidity/complication (CC) and major co-morbidity/complication (MCC) rates, which determine the case mix index. By contrast, nonspecific documentation leads to nonspecific coding. The true severity of illness, mortality rate, and intensity of service are not captured and patient care, data integrity, compliance, and reimbursement all suffer.
Queries can address several areas, for example:

  • to specify the severity of a condition;
  • to clarify the underlying cause of a presented symptom;
  • to substantiate present-on-admission issue; or,
  • to identify a potentially preventable complication.

The physician may answer the query verbally, in writing in the history or physical, in a progress note, or in the query form. Queries may be completed either concurrently (at the time of the physician/patient encounter) or retrospectively.
Ensure queries are clear, concise, and timely by developing clinical indicators to determine when the clinical picture suggests a particular diagnosis. These clinical guidelines should be written in the query template for each condition and updated appropriately. Several organizations offer example templates, or facilities can create their own guidelines based on medical literature (e.g., The New England Journal of Medicine).

Electronic vs. Paper Queries

Automated queries as part of an electronic health record (EHR) provide effective recording, tracking, and charting data from the medical record, and are gaining popularity. There are drawbacks to automated systems, however. If the query is in the queue with several other documents for the physician’s signature, the physician may sign the document electronically without answering the query.
Paper queries can be effective if automation is not an option. For example, at Civista Medical Center in Maryland, a clinical documentation specialist (CDS) attaches a color-coded query form the patient’s medical record. The physician reviews the record, assesses the patient, and answers the query. The CDS records the information in the CDI database, and the query form becomes a permanent part of the medical record.

Build Physician Support

In addition to well-executed queries, a successful CDI program requires the support of administration, ancillary staff members (such as case management), and—most of all—physicians. Physician resistance is high for two key reasons:

1.      Time: Physicians’ primary focus is patient care, and anything that detracts from that immediate goal may be perceived as a distraction.

2.      Education: To achieve accurate and concise documentation, physicians must be educated as to why it is important.

A clear, concise CDI plan must include physicians every step of the way. Here’s where your CDS and physician advisor come in.


The CDS’ role is to support and enhance physicians’ documentation efforts. The CDS is involved in every facet of the CDI program. The CDS formulates query templates, leads the team that delivers (electronic or paper) queries to physicians, records responses, and follows up on unanswered queries. The CDS formulates a working DRG and a target DRG, and evaluates the medical record for secondary diagnosis to increase the severity of illness. Coders review the DRG and secondary diagnosis. If this information helps to optimize the DRG, it is added to the final DRG for reimbursement. The CDS should provide feedback to various facility departments on the CDI program’s impact on quality, integrity, and reimbursement.
A CDS must have clinical knowledge (including anatomy and physiology), a mastery of ICD-9-CM coding guidelines, expertise in health care regulatory compliance, and strong verbal and written communication skills. Having a doctorate, master’s, or bachelor’s degree in a related health care discipline is essential.

Physician Advisor

The physician advisor is a liaison between the CDS, coders, and the medical staff. He or she is responsible for educating physicians on coding guidelines and new clinical terminology, and for optimizing physicians’ documentation of condition severity, acuity, risk of mortality, and intensity of service. The advisor may present information at the monthly staff meetings, assist in the development of queries, address admission denials and DRG modifications, work with health information management (HIM)/CDS personnel, and when necessary, approach physicians with unanswered queries. Together, the physician advisor and CDS should initiate a program to educate physicians about ICD-9-CM (and the forthcoming ICD-10).
The physician advisor is nominated or appointed by his or her physician peers (Physicians generally respond more favorably to a colleague than to administrators or support staff.). The qualified advisor can accurately analyze the health record, understands the complexity of the coding/prospective payment system, and provide in-services on medical conditions.

The Coder’s Role

Your role in the CDI program is paramount to its success. You will be using the query templates retrospectively if the physician does not answer the query concurrently. The CDS should meet with you routinely about documentation issues. You can offer insight on missed query opportunities and share your response rates to retrospective queries, and the effectiveness of the CDS concurrent reviews.
CDSCDI Resources:
Association of Clinical Documentation Improvement Specialist (ACDIS) (www.ACDIS.ORG)
CMS (www.cms.gov)

5 Documentation “Must Haves”

Medical documentation under the MS-DRG system must meet five requirements for quality, compliance, integrity, and reimbursement:

1.            Assign patient status (inpatient or observation)

2.            Assess the risk in the assigned status (inpatient or observation) to determine services ordered

3.            Support medical necessity throughout the patient stay

4.            Reflect that the nurse/attending physician frequently monitored/evaluated the patient

5.            A discharge and transfer note must reflect a summary of care and a final diagnosis

For example, a patient is admitted to the ER with shortness of breath and dyspnea on exertion. During examination, the physician notes that the patient has a wet cough. The patient’s lab work showed a bnp 20,485/dimer 6,000. CXR revealed pulmonary edema/CHF. The patient diagnosis was congestive heart failure (CHF), and the patient was admitted as an inpatient with a Lasix 80 mg IV BID, 02 2L/NC; The CDS queried the physician for the type of CHF—which was not documented by the admitting physician.

The type of CHF (acute, acute-on-chronic, systolic, diastolic, combined systolic/diastolic, or decompensated) will drive the severity of illness and the DRG. Inadequate documentation of the severity of the CHF will cause case mix complexity, underutilization of resources, inappropriate nurse-to-patient ratio, reduced professional compensation, and incorrect perception of care provided.

10 Tips For CDI Program Success

1.      Articulate a Vision Statement. The “vision” of the CDI program should reflect the facility’s goals and desires, including accurate DRG assignment, quality monitoring, and optimal reimbursement.

2.      Look to successful programs for guidance. There are several well-established CDI programs in the health care industry. Contact those CDI programs in your area and ask for tips and guidance. Usually, they are more than happy to share information to help you get started.

3.      Don’t be shy. Establishing a CDI program is a multidisciplinary team effort, so you’ll have to encourage open communication throughout the team.

4.      Get face to face with your team. Electronic or paper communication is acceptable, but especially during the setup and initial phases, personal contact emphasizes the commitment to establish a CDI program.

5.      Accept both positive and negative feedback. A multidisciplinary team may uncover problem areas that you hadn’t considered. Be ready to listen and learn, as well as to contribute your ideas.

6.      Set short- and long-term goals for your CDI program. A short-term goal can be as simple as piloting your CDI program with one service in the hospital before going hospital-wide. A long-term goal can be broadening your outcome measurements. Goals should be challenging but realistic. Don’t set yourself up for failure.

7.      Develop queries for physicians to improve documentation. Include coders and physician advisors when creating the templates. Make sure the query is clear and concise and does not “lead” the physician to document extraneous or incorrect information. Effective queries make a difference in how well physicians respond.

8.      Adopt quality measures. Establish measurable outcomes that can be tracked by all stakeholders, including administrators, coders, physicians, and the CDI team.

9.      Consider a CDI to help prepare you for ICD-10. ICD-10 requires a greater level of documentation specificity than the current ICD-9-CM coding system. Preparation starts now for the Oct. 1, 2013 deadline.

10.   The focus of the CDI program will dictate staffing. The program can be staffed with qualified professionals including HIM coders, nurses, physicians, or a combination of each discipline. If quality indicators, clinical outcomes as well as DRG optimization are important issues, the program may have a combination of HIM coders and nurses. In some programs, physicians conduct reviews and communicate with their peers on documentation issues.

Karen Stanley, MBA, RN, is CDS for Civista Medical Center, Laplata, Md. Karen has 30 years experience in the health care industry. She received special recognition for outstanding performance as a case manager, appeals examiner, and claims auditor at Children’s National Medical Center in Washington, DC. She has been awarded Pediatric Screening Nurse of the Year and was featured in Nursing Spectrum magazine for Kaiser Permanente. Karen served as a medical surgical nurse for five years at King Fahad Hospital in Saudi Arabia. She can be reached at
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