Spring 2025 Issue

Guiding CDI
By Selena Chavis
For The Record
Vol. 37 No. 2 P. 16

Industry professionals weigh in on best practices for improving CDI.

More than ever, hospitals and health systems rely on clinical documentation integrity (CDI) to optimize clinical care, ensure regulatory compliance, and maintain a healthy bottom line. While the value proposition for CDI professionals is high in any provider organization, the territory comes with its fair share of challenges.

Nancy Reading, RN, BS, CPC, CPC-P, CPC-I, expert coding auditor with Elevate Medical Solutions, points out that CDI professionals lack authoritative industry direction. Unlike coding professionals who can look to standards laid out by the CMS, the American Hospital Association, and the American Medical Association, CDI professionals have no clear guidelines laid out by regulators or national association heavy hitters for how often a review should be done, what charts should be reviewed, what volume of records to review, or what clinical parameters should be used to do the job.

“Pinson and Tang and HCPro both publish CDI pocket guides that are in use, but each guide has a different set of authors,” Reading says. “There are still two CDI credentials: AHIMA offers a CDIP (inpatient), and HCPro offers a CCDS (inpatient) and a CCDS-O for outpatient.”

Yet even without clear standards, CDI has carved out a strategic niche that is here to stay. Industry professionals continue to identify best practices to overcome mounting challenges related to resource shortages, reimbursement complexities, and evolving regulatory requirements. While adoption of advanced technology is certainly part of the equation for improving CDI processes, Julie Salomon, BSN, RN, CDI business director for Solventum, emphasizes that health care organizations will always need to strike the right balance with human resources.

“I think organizations are looking at how you marry [people] up with technology so that you can make sure resources are working at the top of their license on stuff that matters,” she says. “I think that’s kind of the challenge, the balance between being able to leverage technology and yet have that expertise that you need.”

Evolving CDI Challenges
Kacie Geretz, RHIA, CPMA, CPC, CCA, director of growth enablement with Nym, notes that health care organizations face an expanding documentation scope—primarily associated with an ongoing shift from an inpatient focus to an outpatient focus—making it nearly impossible to maintain effective and efficient CDI processes from a resource perspective. “Value-based payment models have increased the pressure on organizations to expand CDI efforts into outpatient services. We’re seeing organizations focus more than ever on ensuring appropriate capture and documentation supporting Hierarchical Condition Category codes that directly impact reimbursement,” she explains.

Resources and continued reliance on manual processes are a significant challenge. Geretz says that in her experience, most provider organizations still prefer using clinicians for CDI roles despite the nationwide clinician shortage. “This is likely a result of how difficult it is to find skilled staff at affordable rates within the US, paired with the fact that successful offshore options with CDI expertise are still limited,” she adds.

In addition, there is a shortage of CDI professionals due to the unique skill set required, says Carrie Kuchenbacker, RHIA, CCS, CDIP, expert coding manager at Elevate Medical Solutions. “Health care organizations generally do not understand the benefit of hiring a CDI specialist until they see the data showing improved fiscal outcomes published by institutions using a CDI team,” she notes.

Keeping up with evolving regulatory requirements adds strain to the resource issue. Kuchenbacker says that lack of published compliance or payer regulations directed at CDI activity leaves queries and errors in the crosshairs for regulatory compliance. “Third-party payer denials for the inpatient arena have moved to a clinical-based model in addition to a coding-based activity,” she explains. “CDI staff are used to intervene with the providers regarding denials to formulate appeals, identify documentation integrity trends and deficiencies, and educate the providers in an effort to avoid making the same mistake twice.”

Geretz agrees, pointing to the struggle of inconsistent documentation standards. “We hear about it all the time: health care providers have to navigate ambiguity, inconsistencies, and frequent changes in documentation standards across different payers, including CMS and various managed care organizations,” she says. “These shifting requirements create ongoing compliance challenges that require constant adaptation.”

Adding fuel to the fire, health system integration complexities are growing, leading to more scrutiny around professional evaluation and management codes as more physician groups join health systems. Geretz also points out that with physician payments continuing to decrease while operations costs remain stable or increase, “we’re seeing organizations working to maximize every RVU [relative value unit] on the professional side. This introduces a subset of outpatient CDI that requires a completely different skillset than traditional CDI.”

Elevating CDI With Technology
According to National Institutes of Health, “the future of … CDI will require expanding the reach of CDI programs into new areas of expertise because the traditional realms of CDI work are increasingly becoming automated.” AI and machine learning have become a valuable asset to clinical processes, says Reading, who adds that “these technologies also present the potential for transforming administrative functions such as coding and clinical documentation.”

AI and predictive analytics are helping many health care organizations identify documentation issues before they become billing problems, Geretz notes. “These tools can function as early detection systems for documentation gaps before they affect revenue cycle outcomes,” she says.

From the physician perspective, ambient listening AI technologies are playing a transformative role in documentation by capturing provider-patient conversations and converting them into structured documentation. These solutions reduce the documentation burden on providers while also improving quality and comprehensiveness, allowing clinicians to focus on patients rather than screens, Geretz explains.

Industry professionals agree that there is a growing need to incorporate advanced technology into CDI processes to relieve resource strain, streamline operations, and speed reimbursement. Salomon emphasizes that technology is not a panacea, though, and suggests that it will play a complementary role. She points to the struggle of finding qualified coders as an example, emphasizing that while CDI is a little behind where coding has been, the profession is very much on the same course.

“When we’re looking at taking advantage of technology for coders, it’s really allowed us to free up those resources to do other kinds of work that are more complex, that technology cannot handle,” Salomon says, noting that using technology in this area is a big part of the conversation she has with executives, especially finance. “Finance is always looking at ‘how can we cut resources, saving cost?’ And then the other leadership is looking at what redundancy and manual efforts we can take out so that we can use those resources elsewhere because resources are so scarce.”

Salomon suggests that when looking at human resources vs technology, some key questions to ask are: Are we using them wisely? Are they doing the right work? Are we touching work that we don’t need to touch? “I think that’s where technology can really help us. It can help us get to the work that matters, where we can make a difference,” she adds.

Geretz says that one area where technology can improve the CDI outlook is with ongoing EHR documentation challenges such as “note bloat,” which prolongs the process of coders and CDI professionals finding relevant clinical information amid lengthy, template-driven documentation. “The industry is still addressing the consequences of the HITECH Act of 2009, which accelerated EHR adoption but created new documentation challenges like excessive copy-paste content and note redundancy that are still lingering today,” she says.

Getting ahead of note bloat will also be critical for combating payers’ heavy investments in AI, which they are currently using to ramp up denials, Salomon notes. “I think payers probably have a little bit of an edge there, because they have more resources to create technology that looks for something that they would potentially deny. Plus, they can cast a wide net. They don’t seem as concerned about the noise that they’ll create for the providers, for the physicians.”

Elevating CDI With Professionals
Technology is an important component to optimizing CDI processes, but industry professionals point to a number of “people process” trends that will be critical to extracting the full potential of a CDI strategy.

Notably, Geretz suggests that health care organizations adopt the following:

• Continuous Education and Audits: Organizations must recognize that regular CDI and coding team audits, coupled with targeted provider education, create a feedback loop that consistently improves documentation practices.

• Meaningful Query Processes: Geretz says that she has seen a growing emphasis on ensuring queries follow the Association of Clinical Documentation Integrity Specialists and AHIMA rules while focusing on query impact rather than just query volume. “Organizations now understand that physicians are more likely to engage with queries that demonstrate clear value for their limited time,” Geretz emphasizes.

• Data-Driven Engagement: Successful teams are investing time into convincing providers and physician leadership with compelling data about the financial impact of proper documentation.

• Proactive Payer Rule Management: Leading organizations have Managed Care Teams anticipating payer rule changes and informing key stakeholders before new requirements impact compliance.

• Organizational Alignment: Progressive health care systems are reducing barriers between clinical staff, coding, and CDI teams by aligning everyone around a shared purpose that addresses both patient care and appropriate reimbursement.

Salomon says CDI teams are starting to collaborate in different spaces than they have previously. She points out that in the early years of CDI, the focus was to ensure everything was current. “The further upstream we can get, the less back-end work we have to do. But we do see some folks that are really focused on that prebill retro space, where they’re trying to play catch up on maybe what was missed,” Salomon explains. “I think that we want to catch all that, but trying to reverse the denial that’s already occurred is a huge lift. It’s very resource consumptive, be it the inpatient space or preauth in the outpatient. You’re going to spend a lot of time and effort, a lot of resources for something that you won’t be able to move.”

Instead, Salomon suggests looking for ways to become more proactive and spend resources in those areas. “Look at what matters and what we can do something about, instead of wasting more money and resources on chasing things that aren’t going to make a difference in the end,” she emphasizes.

Finally, industry professionals agree that physician champions will continue to play a critical role in optimal CDI strategies. Geretz says that this essential element is all too often overlooked in CDI discussions, although the impact of dedicated physician champions who genuinely believe in the value of appropriate documentation practices is significant. “Without committed clinical leadership support, even the most sophisticated CDI program will struggle to gain traction,” she says. “I believe that physicians who can translate CDI concepts to their colleagues in relatable clinical terms are invaluable assets that can make the difference between program success and failure.”

— Selena Chavis is senior director of accounts with Insenna and a Florida-based freelance writer.

 

Staff Most Involved in Shaping CDI

As health care organizations continue to refine and expand their clinical documentation integrity (CDI) strategies, the number of people involved in shaping processes are also expanding. Kacie Geretz, RHIA, CPMA, CPC, CCA, director of growth enablement with Nym, offers the following insight into the “who” behind CDI in today’s health care organizations.

Clinical Documentation Leadership: CDI directors, their teams, and specialists bring specialized expertise that forms the foundation of effective documentation improvement initiatives. They serve as key bridges between clinical and revenue cycle worlds, translating complex coding requirements into actionable strategies.

Financial and Compliance Teams: Revenue cycle and coding leadership provide critical perspectives on how documentation practices directly impact financial outcomes. They’re adept at converting documentation gaps into quantifiable revenue impacts that resonate with leadership across the organization.

Clinical Leadership: Physician leadership and nursing leadership offer essential insights into workflow realities and clinical documentation approaches. Their involvement makes the difference between CDI programs that look good on paper and those that actually work in the real clinical environment.

Utilization Management: Utilization management leadership ensures resource allocation and medical necessity documentation meet requirements while supporting appropriate reimbursement. They’re increasingly vital in preventing denials through documentation that clearly justifies the level of care provided.

Payer Interface Specialists: In today’s landscape, managed care teams have become crucial participants in shaping CDI processes. Their understanding of payer-specific requirements helps organizations navigate the increasingly complex web of documentation standards.

Integrated Team Approach: In order to be successful, a CDI team has to be a cross-functional team made up of revenue cycle management, clinicians, CDI specialists, coders, etc that, at the end of the day, remain focused on the primary driver behind our shared purpose: our patients.

— SC