By Dave Friedenson, MD, FACEP, Chief Medical Officer
Clinical documentation is undeniably the foundation of quality patient care and accurate reimbursement. It’s also a critical area of opportunity.
Introducing clinical documentation improvement (CDI) programs is a proven strategy for enhancing the accuracy and completeness of medical records, contributing to better clinical outcomes, more efficient resource allocation, and reduced risk of claim denials.
The benefits are substantial. The risks of not having a robust CDI program in place are just as considerable. The financial integrity and reputation of a healthcare organization could be undermined if risk adjustment scores or clinician quality profiles don’t accurately reflect patient acuity.
Despite the benefits and the risks, healthcare organizations still seem hesitant to adopt these programs.
Understanding CDI Misconceptions
Obstacles to CDI program implementation could include more overt challenges, such as staffing shortages. But, the easiest barriers to address today are less tangible: misconceptions that feed resistance to change and lead to a lack of support from key stakeholders.
Below, we debunk the top 5 myths and misconceptions associated with CDI programs and explore how these initiatives streamline operations and improve patient care in reality.
1. Myth: CDI Only Improves Inpatient Hospital Revenue
CDI programs are solely designed to boost inpatient revenue and control costs through optimized billing processes — in particular, those associated with diagnosis-related groups (DRGs).
Reality: CDI Programs Can Enhance Outpatient Physician Reimbursement and Quality
CDI is much more than a revenue-driving tool for hospitals; it can bring significant financial benefits to outpatient providers as well. It also plays a crucial role in improving physician quality — and, as such, the quality of care patients receive.
The professional and hospital sides of CDI each have distinct coding standards and processes. While hospitals focus on DRGs, physician billing follows current procedural terminology (CPT) codes. Errors in documentation on either side can impact care quality, compliance, and reimbursement, making CDI an essential tool for both.
Professional CDI programs focus on empowering physicians with the tools, resources, and continued training they need to capture the full scope of care they provide, ensuring compliance with coding requirements, reducing the risk of claim rejections, and ultimately optimizing physician reimbursement.
But, most importantly, improved clinical documentation from physicians on the professional side can facilitate smoother transitions of care between different settings, whether from physician to hospital or across departments, leading to a more seamless and coordinated approach to patient management. The clearer the picture of a patient’s health, the easier it is for physicians and hospitals alike to deliver tailored and timely care.
2. Myth: CDI Programs Add to Provider Workloads
CDI initiatives require providers to spend more time on documentation and the administrative tasks associated with these programs, such as training, which exacerbates full workloads and detracts from direct patient care.
Reality: Robust CDI Bridges the Gap Between Effort and Accuracy
There is no denying that clinical documentation, though imperative for clinical care, is a massive administrative burden for providers. In fact, a study from 2019 estimated that U.S. physicians spend approximately 125 million hours documenting outside patient visit hours.
Yet, that time spent is not translating to quality documentation. According to an HHS report, rates of improper documentation can range from 35.5 percent for established office visits to 29 percent for initial hospital visits and more than 55 percent for subsequent hospital visits.
Well-designed CDI programs are not developed as time-saving solutions. They are developed to bridge the gap between effort and accuracy in documentation.
Through a combination of root cause analysis, peer-to-peer feedback loops, on-demand training, and tech enablement, comprehensive programs educate providers on how to document the right information upfront and empower them with the tools to do so. It’s not about doing more work; it’s about doing the necessary work more efficiently.
The end benefits can include time savings, such as reduced hours spent on corrections. But, they also include clarity on documentation best practices to support consistency, compliance, and accurate reimbursement — and, most importantly, higher-quality patient care and improved clinical outcomes.
3. Myth: Technology Alone Can Solve Clinical Documentation Challenges
For CDI to be effective, little human intervention is needed. Instead, relying on advanced software and tools such as artificial intelligence (AI) and natural language processing (NLP) to surface errors will ultimately enhance documentation accuracy and compliance.
Reality: Effective CDI is a Human-First Approach
Throwing technology at providers isn’t enough. These tools are powerful, but they are not a panacea for all clinical documentation challenges. Technology can easily overlook the nuanced clinical scenarios and contextual understanding necessary for truly effective CDI.
That’s why robust CDI programs are tech-enabled but human-first.
For example, AI can be used to flag potential gaps in documentation or coding errors, but seasoned clinicians are necessary for providing oversight, including determining whether or not an error is a one-time inconsistency or a pattern by department. These experts provide the peer-to-peer feedback providers need (and deserve), ensuring that feedback is relevant, accessible, and actionable.
Similarly, electronic health records (EHRs) typically have a standard template providers use for documentation. These templates may or may not be user-friendly; they may not enable providers to document comprehensively without hunt-and-click burden. As part of CDI programs, specialists can collaborate with providers across departments and healthcare organizations to customize these templates to meet providers’ needs, making the technology work for them.
4. Myth: CDI is a One-Time Project
CDI requires a single-push implementation effort with lasting improvements, remaining effective without further intervention. Or, it is a temporary initiative with equally temporary benefits.
Reality: CDI is a Change Management Initiative
CDI cannot be a one-time project, or it will only provide temporary benefits.
The healthcare landscape is constantly evolving: Patient populations’ needs evolve, regulations and payer expectations change, coding standards update annually, and best practices fluctuate as a result. The rules are not intuitive; physicians tend to forget them over time.
CDI programs must be equally dynamic — an ongoing process that requires continuous monitoring, adaptation, and improvement to ensure long-term success.
An effective CDI program is a change management initiative. It prepares, supports, and equips providers to adapt to new documentation requirements, remain compliant, and adopt new technologies — without added burden. Regular assessments, peer-to-peer feedback loops, and training address knowledge gaps, resistance to change, and foster a culture of continuous improvement.
CDI programs as change management initiatives provide the flexibility and scalability needed to accommodate shifts and support the organization’s goals for better patient care and financial performance through sustainable enhancements in documentation quality.
5. Myth: Outsourcing CDI Causes More Headaches
Outsourcing clinical documentation improvement leads to a loss of quality and control over the documentation process. External CDI servicers don’t understand the unique needs and standards of individual organizations, leading to misunderstandings, missed opportunities, and inefficiencies.
Reality: The Right CDI Partner Empowers Organizations with Targeted Expertise
The right CDI partners don’t take over clinical documentation. They develop and implement customized programs that allow healthcare organizations to take back control of their documentation processes.
These partners bring specialized expertise and experience — as well as the outside perspective — needed to identify issues, pain points, and other areas of opportunity that may have been overlooked. They work across the organization to gather insights and develop flexible systems that enhance documentation within and across departments. They introduce tech efficiencies, including AI-enablement and process automation, as well as customizable solutions that integrate with existing EHRs. And, they take on the onus of navigating complex regulatory and payer expectations, staying up to date and relaying necessary information as actionable insights via robust training.
The right CDI partner empowers organizations to continuously improve and maintain documentation practices, shouldering administrative burdens so providers can focus on the high-value activities that improve patient outcomes and maximize compliant financial performance.
Myths, Debunked: CDI Programs in Reality
The misconceptions associated with CDI programs shouldn’t deter healthcare organizations from reaping the full benefits of these initiatives. A well-executed CDI program is far from an added burden or a simple tech solution — it is a transformative approach that enhances the accuracy of medical records, supports better patient care, and optimizes financial performance.
For organizations hesitant to embrace CDI programs, it’s time to reevaluate. Partnering with the right experts can make the difference, with tailored solutions that fit your specific needs and drive improvements that resonate across the entire healthcare ecosystem. Effective CDI is not just a task to be checked off — it’s a critical strategy for long-term success.
Learn More
Discover how Omega Healthcare Management Services’ CDI-led coding solution improved provider engagement, E&M, and wRVUs at a large academic physician group.