Two-thirds of hospitals recently surveyed have a clinical documentation improvement (CDI) program already in place.[i] That’s the good news. The bad news is that existing CDI programs are only 70 percent effective, according to survey respondents, with an average effectiveness rating of 3.25 out of a possible 5 points.

With ICD-10 looming and the importance of clinical documentation growing, providers are under intense pressure to improve existing CDI programs or rapidly implement new ones. Our experience working with hospitals nationwide points to three factors for CDI success: audits, queries, and case mix.

Audit Your Program

In the aforementioned recent survey, facilities that failed to audit or assess their CDI efforts rated their programs’ overall effectiveness 20 percent lower than those that conducted regular audits. The message is clear: if you want to be successful, audit your CDI program regularly.

Conducting a CDI audit is like getting a tune-up for your car before a long drive. The audit identifies critical problems, gives you time to repair them, and ensures a safer journey. And according to ICD-10 early adopters, you better wear your seat belt. ICD-10 is going to be a bumpy ride! Speakers at the recent Healthcare Information and Management Systems Society (HIMSS) ICD-10 Symposium reiterated that the lack of clinical documentation is causing problems. And additional time definitely will be needed to document cases using ICD-10 properly.

Only by conducting an audit of your CDI program, in tandem with dual coding, can organizations identify gaps in clinical documentation that could lead to coding and billing issues in ICD-10. Questions to ask when auditing an existing CDI program include:

  • What metrics are you monitoring, and are they good predictors of downstream impact?
  • Who will use the dashboard and how will it impact their role(s) in the organization?
  • What actionable steps will be taken in response to the data?
  • If physicians are found to be deficient in a certain aspect of documentation, what occurs?
  • Are physician query response rates and compliance covered in your medical staff bylaws?

Streamline Your Query Process

Physicians and coders speak different languages. Even well-written queries are sometimes lost in translation. Now is the time to reassess physician queries with an eye toward ICD-10. New ICD-10 terms, definitions, and vernacular should be incorporated into templates. As always, queries must not be leading.

Focus efforts on physician outliers, or those who have continued to push back in response to documentation improvement requests in ICD-9. Use anticipated ICD-10 DRG shifts, potential reimbursement losses, and quality scorecards as new incentives to promote physician participation, engagement, and compliance. Some organizations begin with high-paying DRGs, frequently occurring DRGs, targets of RACs and other payor auditors, or frequently denied claims and codes. CCs and MCCs are two more good places to target CDI efforts.

Some providers start with assessing known ICD-10 hot spots, as listed below.

  • Orthopedics
  • Cardiology
  • Obstetrics
  • Behavioral Health

Clarify the CDI/Case Mix Relationship

Despite the beliefs of many executives, improving documentation and increasing case mix are not the same thing. Case mix becomes more accurate, but not necessarily of a higher volume, when CDI efforts and coder accuracy are in sync and vigilantly monitored. Many leaders falsely assume that if cases are documented correctly, the case mix index (CMI) naturally increases – but it’s not true. CMI becomes more accurate, assuming that the coder codes each case correctly.

Good clinical documentation improves case mix only to the extent that it accurately and completely documents the acuity of patients’ episodes of care; then, cases are coded correctly.

Super-Size Your CDI Journey

Now is the time for organizations to expand their CDI programs from two lanes to four, six, or even however many there are on a mega-highway. For the estimated 33 percent of hospitals that have not yet started, external consultants can help cost-justify the investment and jump-start your program.

Correctly documenting for the care you deliver has always been a necessity. With ICD-10, it is your primary lifeline!



Suggested Table: The Importance of CDI Audits

Effectiveness of CDI Programs Where Audits Were Conducted By:

(1=Not Effective, 5=Very Effective)


Both Internal and External Auditors


External Auditors Only


Internal Auditors Only


No Audits Performed

“The State of HIM:” A Study of The Impact of ICD-10, CDI and CAC Initiatives Within the Health Information Management Community. Barron, Roanen. Barron Professional Consulting Services, LLC

About the Author

Torrey Barnhouse is the founder and president of TrustHCS, a firm dedicated to serving the coding, auditing, ICD-10 preparation, clinical documentation, and revenue integrity needs of healthcare organizations. Currently, Torrey serves on the American Health Information Management Association (AHIMA) Foundation Board and the Remington College HIM National Advisory Board. He is a regular contributor to the Coding Compliance Blog, the Health Information Management Association, For the Record, and many other publications. He is a national speaker and author on a number of industry-related topics and holds a bachelor’s degree in psychology from Abilene Christian University.

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[i] “Tracking the Journey to ICD-10.” Barnhouse and Rudman. Presented at the AHIMA ICD-10 and CAC Summit, April 2013, Baltimore, Md.

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