December 19, 2016

CDI Improvement or Integrity?

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When I first entered the CDI field in 2012, I was taught that the acronym stood for clinical documentation improvement. Several years later, my department at University Hospitals Health System in Cleveland transitioned to calling it clinical documentation integrity, and we got new lab coats! 

I Googled it to determine when the profession made the switch, but I couldn’t really find anything definitive. So since I am a relative newcomer, I sought out one of the pioneers in the field, James S. Kennedy, MD, CCS, DCIP, CCDS to get the scoop.

First, we need a little historical perspective. The Health Care Financing Administration (HCFA), which evolved into CMS (the Centers for Medicare & Medicaid Services) instituted the CMS-DRGs (diagnosis-related groups) in 1983 as the payment methodology for the Inpatient Prospective Payment System (IPPS). 3M developed the All-Payer DRG system (AP-DRG) in 1987 for the state of New York to address reimbursement for the non-Medicare population (e.g., obstetrics and newborns). This evolved into the All Patient Refined DRG system (APR-DRG) in 1990 to be able to stratify severity of illness and risk of mortality over all patient populations. CMS replaced the CMS-DRGs with the Medicare Severity DRGs (MS-DRGs) for Medicare’s IPPS, and a three-tiered structure (no CC/MCC, with CC, with MCC) replaced the previous two-tiered system (no CC, CC) effective Oct. 1, 2007.

Hospitals recognized that suboptimal physician documentation often misrepresented the severity and complexity of patients, which downgraded the DRG. 

In response, programs were instituted with professionals who were knowledgeable about coding and clinical medicine and could solicit a clarification from the physician or other healthcare provider. There is no sentinel paper declaring the advent of the very first hospital-based CDI program, but there were consulting firms focusing on this as early as the late 1980s (e.g., Hyatt, Imler, Ott and Blount, now a subsidiary of 3M; DRG Review Inc., founded by Garry L. Huff, MD and William Haik, MD). University Hospitals Case Medical Center started its program in the early 1990s. The earliest programs were more about DRG management, whereas the intent was to accurately portray the patient’s condition and support the intensity of patient evaluation and treatment, such that the reimbursement was commensurate with the resources expended.

In practice, the healthcare system started experiencing DRG creep, which alarmed the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), which expressed concerns that institutions were deliberately using queries to force a response from a physician, which fraudulently upgraded the DRG. In 2001, AHIMA (the American Health Information Management Association) produced a practice brief, “Developing a Physician Query Process,” which laid out the fundamental rules of compliant query practice.

In September 2002, several publications came from the AHIMA convention, which seemed to present the first formal naming of clinical documentation improvement (The Evolution and Implementation of Clinical Documentation Improvement, Russo, Ruthann and Dunleavy, Kathleen; CDI: A Work in Progress, Jackson, Joy and Tadwalt, Bobbi), although the term had long been used in the industry.  

This is where Dr. Jim Kennedy comes in. He was one of the forerunners in this domain, and Jim’s opinion was that clinical documentation “improvement” made it sound like it was more documenting for dollars than a pure desire for accurate representation of the patient’s acuity and severity. He coined the phrase, “clinical documentation and coding integrity” in 2003 and has been using that expression since.

The first time my old boss, Jim White, corporate director of health information management (HIM) floated using the word “integrity” instead of “improvement” with me in September 2014, I was immediately on board. The definitions of “integrity” (per Merriam-Webster Unabridged Dictionary) include the following:

  1. Firm adherence to a code of especially moral values: utter sincerity, honesty, and candor: incorruptibility;
  2. Soundness; and
  3. The quality or state of being complete or undivided: entireness, completeness.


Isn’t that to what we aspire? It immediately elevated the level of our interaction with the medical record from trying to get providers to give us names for conditions suggested by clinical indicators to striving to ensure that the documentation was sound, complete, honest, and accurate. We recognized that if we tell the story of the encounter accurately, the quality measures and reimbursement fall into place.


There was a similar eschewing of the term “emergency room” in favor of “emergency department” at the beginning of my career as an emergency physician. “Room” was a throwback to when it was not a vocation, but an avocation, when doctors with a year of training ran the show as opposed to board-certified emergency physicians. You can still hear both terms used, but we emergency practitioners strongly prefer “department.”

Excellent documentation should help us take excellent care of our patients. We want it to demonstrate acuity, complexity, and severity so that our quality measures reflect that excellent quality of care. We need the reimbursement to be appropriate to the expenditure of resources (no mission, no margin). Having “integrity” as part of our title indicates to others that we are not doing this for the wrong reasons. 

Another maven in our field, Dr. James Fee, pointed out to me another practical reason why the word “improvement” has persisted. Since that is what people enter into an Internet search, people continue to use it to enhance search engine optimization. Is that a wrong reason?

So when should you use “improvement,” and when should you use “integrity?” I believe we should all transition to “integrity” under all circumstances. Malcolm Gladwell defines the tipping point as “that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire.”

I hereby propose that we all tip to having CDI stand for clinical documentation integrity.

It is what we do and who we are.
Erica E. Remer, MD, FACEP, CCDS

Erica Remer, MD, FACEP, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, clinical documentation improvement (CDI), and ICD-10 expertise. As a physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she has trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and the co-host of Talk-Ten-Tuesdays. She is also on the board of directors of the American College of Physician Advisors.