What is Clinical Documentation Integrity (CDI)?

Clinical Documentation Integrity (CDI) is the process of ensuring that the patient's medical record (EHR/EMR) accurately reflects the patient's severity of illness, intensity of services, and the specific reason for the encounter.

CDI is the bridge between the clinical encounter and the financial outcome, ensuring the documentation supports the maximum legal and ethical reimbursement for the services rendered.

Why CDI is Critical for CFOs and Financial Leaders

CDI is a critical safeguard against Revenue Leakage and non-compliance, directly impacting financial integrity.

• Accurate Reimbursement: If documentation is vague, it can lead to under-coding and underpayment. Strong CDI ensures the organization is accurately capturing the full value of the services provided, preventing Revenue Leakage.
• Compliance and Audit Risk: CDI is essential for meeting regulatory requirements (e.g., ICD-10 and CPT coding rules). Poor CDI is a primary trigger for audits and can result in fines for improper billing.

Key Use Cases: How Automation Enhances CDI

RCM Automation uses AI to scale CDI review processes far beyond traditional manual chart reviews.

• AI-Assisted Documentation Review: RCM platforms use Artificial Intelligence (AI) and Natural Language Processing (NLP) to review clinical notes in the EHR in near real-time. The system flags discrepancies between documented conditions and planned procedures, or identifies missing key terms required for specific codes.
• Targeted Physician Queries: The automation system can generate specific, targeted queries back to the provider. This ensures documentation is corrected before the claim is finalized, improving Charge Capture and Coder Productivity.

CDI vs. Medical Coding

CDI happens before Medical Coding:

• Clinical Documentation Integrity (CDI) ensures the clinical record is accurate and complete, providing the necessary evidence.
• Medical Coding is the assignment of standardized, numeric codes to the services and diagnoses contained within the final, accurate documentation.

Resources and Education

• Candid Health Blog: CDI Best Practices /blog/cdi-best-practices
• RCM Solution: Automation Solutions /solution