Learn the Ins and Outs of CDI Best Practices

Posted on 27 Jan, 2018 |comments_icon 0|By Elizabeth

CDI is gaining more importance, and improvement programs have increased across providers over the last 10 years. In fact, CDI has made some positive changes in reimbursement because payers’ increased scrutiny has resulted in value-added changes to patient care.

Best bet: CDI is a quality initiative to which physicians need to pay close attention. Complete, accurate documentation provides the requisite transparency of, and access to, information, such as the quality of care between the physician and the patient – and even between different physicians and other healthcare professionals.

Complete and accurate documentation clearly shows what services have been performed, what the diagnosis is for the patient, what are the expected next steps are for treatment.

The VIPs of CDI

You already know about CDI VIPs – the coder and practice manager – and the role they play in coding, billing, and reimbursement. But who are the other VIPs in the CDI game? Let’s take a look at these important positions and how practices can fill them.

Make the Grade with Your Own CDI Team

CDI Team – In addition to the coding and billing staff who monitor, audit, and check documentation, the CDI team consists of physicians and mid-level providers who compose the majority of the clinical documentation, along with nurses and medical assistants, who also contribute to documentation in the EMR.

A CDI team consists of:

  • Physicians
  • Mid-Level providers
  • Nurses/Medical Assistants
  • Coders and Billers
  • Clinical Documentation Specialist

A Clinical Documentation Specialist (CDS) facilitates CDI through regular and focused follow-up with providers and arranges or provides education on CDI best practices, guidelines, and regulations to the care team. The CDS is ultimately responsible for the prompt acquisition of accurate, detailed, and comprehensive information used in healthcare analytics and patient care outcomes.

Should all practices hire a CDS?

Practice managers usually decide between two options: Hiring a consultant to pitch in where needed, or transforming one of their top coders or billers into a clinical documentation specialist.

Strategy: Before coders and billers become a CDS, they must be on board to fully translate what has been documented in the medical record into codes used for billing. They should be well-versed in CDI regulations and guidelines and able to identify and address trouble spots in patient records.

Bird’s Eye View: The CDS or consultant works with the team to resolve problems with the documentation, eliminate weakness in the EMR, and devise training education and tips to help practitioners learn to simplify and streamline processes.

Hail to Specificity

Lack of detail can severely affect a physician’s payment, especially with ICD-10 now in force. There will be times when a provider can’t avoid using an unspecified code because he does not know the exact condition, such as with an evolving sepsis. He might not be able to identify the exact bacteria at that point in time.

Similarly, the provider may see a patient with myocardial infarction but is uncertain which part of the heart has been affected. To document for coding and billing, he will have no choice but to use an unspecified code.

Downside: Continuing to use unspecified codes indiscriminately will affect reimbursement for providers, as payers increasingly demand the highest level of specificity possible in coding.

Tip: Always document and code to the highest level of specificity. Coders and practitioners would be wise to end their dependency on unspecified codes now, and save them for the truly occasional situation.

Beware: As ICD-10 continues to grow in specificity, those physicians who rely on assigning unspecified codes will find themselves in a reimbursement conundrum, as payers deny more of their claims due to ambiguous diagnoses.

Reality: Old habits die hard when it comes to using unspecified codes. CDI is all about making sure that providers are well-educated on the specifics of documentation, such as the code for the precise anatomical location of the infraction within the heart.

Incomplete documentation can adversely affect payment, as insurance companies do not support using unspecified codes.

Bird’s Eye View: It helps to view the situation as an auditor: They do not tolerate ambiguity in coding because it leads to denied claims.

Remember: If coders do not question ambiguous documentation so that they can code to the highest level of specificity, reimbursement is denied or lowered because the documentation does not accurately explain the level of care.

Physicians who document incorrectly or insufficiently may find themselves facing legal ramifications, such as malpractice suits, along with decreased reimbursement. Providers must have training and education on how to meticulously record all facets of the patient’s services or procedures. They also need to understand the coding process and how poor documentation adversely affects coding. Providers don’t learn about coding in medical school; coders, practice managers, billers, and auditors must teach coding to providers on-the-job.

Conquer CMS Principles of Documentation

The following points identify CMS guidelines for correct documentation that supports and validates the claim submitted for services/procedures:

  • The record of the encounter/episode of care should be complete and legible
  • Documentation should include:
    • Reason for the encounter
    • Assessment, diagnosis, and clinical impression
    • Medical plan of care
    • Date and legible identity of observer
  • Rationale is documented for ordering diagnostic and ancillary services
  • Past and present diagnoses are documented
  • Diagnosis and treatments are supported in medical record and match the codes reported on the CMS-1500 for the patient’s services

Caution: Lack of a valid reason for an encounter is one of the most frequent pitfalls that leads to a denied claim, which could be because a patient may not present with a chief complaint (CC), or it’s difficult to determine the reason for the encounter, or when the CC does not correlate to the components of the assessment.

Bottom Line: A missing explanation for the encounter is one of the most commonly reported problems with documentation.

Learn More

Master accurate and timely documentation that reflects the scope of services provided with TCI’s Clinical Documentation Sourcebook 2018.



Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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