Updated on: March 14, 2016

Developing a Clinical Documentation Improvement Program for Your Physician Practices

Original story posted on: January 10, 2014

Happy New Year! This is a year of significant change. Of course, I am talking about the ICD-10 transition, which will be the most significant change I have seen in the 32 years of my healthcare career. I know many of you are getting very nervous – especially those of you who have not started your ICD-10 implementation work. 


As I travel around the country working with many types of providers, including physician groups and hospital-owned physician groups, I am finding a common denominator. Clinical documentation improvement (CDI) is often missing from ICD-10 plans for the physicians. The hospitals are thinking about their own CDI plans, but not about their employed physicians.

Keep in mind that documentation begins and ends with the physician. So if the hospital’s clinical documentation is not sufficient, the place to start addressing it is not just within the hospital, but also within the physician practice.

I recommend that every medical practice, whether independent or part of a hospital group, develop a CDI protocol. What does that really mean? Hospitals can purchase software to assist with data mining to determine what records to review and develop an automated query process. But what can the physician practice do for CDI? It will be so important with ICD-10 to ensure that your practice is staying on top of clinical documentation and performing accurate ICD-10 coding.

One of the interesting lines I sometimes hear when I speak to physicians is that “we got paid, so it must be right.” They falsely assume that every paid claim is accurate and are not really certain what they need to document to get paid appropriately. What about their billing and coding policies? I recently came across a large hospital-owned physician practice (not one of my clients) that was billing preventive visits and problematic visits for every patient they wrote a prescription for. I asked, how they could do this? The answer they gave was that they forced every patient who scheduled a preventive visit to sign a document indicating that they understood if the physician discussed anything about their medical condition, including the need for renewal of prescriptions, a level 3 (99213) visit would be billed in addition to the preventive medicine visit. Is this method of coding and billing correct? I don’t believe it is. Where was administration in all this? How could the coding and billing rules be so misinterpreted, and who pays the price? 

When I questioned a couple of the physicians in the group, they both told me that administration told them to do this. A lot of coding and billing errors similar to this could be eliminated with a CDI program in place. I firmly believe it is just as important for compliance and reimbursement in this setting as it is in the hospital.

What does CDI really mean, though? CDI refers to the process of improving documentation to better reflect the severity of each patient encounter. Imagine if physicians were paid based on severity of illness versus RVU (Relative Value Units)? Do you think their reimbursement would increase or decrease? I would bet it would decrease significantly if payment was based on the current documented diagnoses. ICD-9 and ICD-10 codes alike justify medical necessity for services rendered and assist with supporting medical necessity for each  evaluation and management service level reported. ICD-10 will change or modify how practitioners document and code patient encounters. Clinical documentation is not by any means “all about the money.”

Clinical documentation affects many quality metrics, including:

  • Adherence to standard medical practices and standards of care;
  • Medical necessity (diagnosis codes);
  • Quality and outcomes measures;
  • Measures of efficiency and effectiveness;
  • Medico-legal purposes;
  • Adherence to Joint Commission standards and other requirements; and
  • Basis and support of reimbursement for services rendered.

The fact is, when documentation is insufficient, incomplete or incorrect, insurance companies, Recovery Auditors (RACs), Medicaid Integrity Contractors (MICs), and others can take back payment with fines and issue penalties in some instances. By developing a solid CDI program, risks can be significantly reduced. Because documentation issues will be at the forefront with ICD-10, it is important that every ICD-10 steering committee take a good look in developing a CDI program.


Review this documentation example comparing ICD-9-CM documentation to ICD-10-CM documentation:

Pre-eclampsia antepartum with gestational diabetes

ICD-10 clinical documentation will need to specify a) trimester, b) pre-existing or gestational diabetes, plus diabetes type, and c) other maternal diseases complicating pregnancy (i.e., anemia, obesity, alcohol use, smoking, mental, digestive disorders, etc.) – and for obesity, include BMI and the source of obesity (excess calories or due to medication).



Clinical Documentation

ICD-9 Code

Clinical Documentation

ICD-10 Code

Lisa comes in for her monthly OB check at 30 weeks. She has been having headaches, nausea and vomiting. She thought she was getting the stomach flu. She has no fever, but her blood pressure is 150/90.

Blood sugar indicates gestational diabetes.

Lisa has also gained over 8 lbs since her last visit. Cumulative weight gain during pregnancy is over 60 lbs.  Obesity prior to pregnancy.

Impression: Gestational diabetes with pre-eclampsia and obesity

642.43 mild or unspecified
pre-eclampsia, antepartum

648.00 diabetes mellitus complicating pregnancy, unspecified

278.00 Obesity, Unspecified

Lisa comes in for her monthly OB check. She is at 30 weeks (third trimester) She has been having headaches, nausea and vomiting. She thought she was getting the stomach flu. She has no fever, but her blood pressure is 150/90.

Blood sugar indicates gestational diabetes, which is under control with insulin. Gestational diabetes affected her first pregnancy.

Lisa was 5-foot-4, 175 lb. BMI 30.0 at onset of pregnancy.  She is now 235 lbs.

Impression: moderate pre-eclampsia with gestational diabetes, Morbid obesity due to excess calories

O14.03 moderate pre-eclampsia, third trimester

O24.414 gestational diabetes mellitus in pregnancy controlled by insulin

O99.213 obesity complicating pregnancy, third trimester

E66.01 Morbid (severe) obesity due to excess calories

Z3A.30 pregnancy single uterine, 30 weeks gestation

Z86.32 personal history of gestational diabetes

Now review this example:



Clinical Documentation

ICD-9 Code

Clinical Documentation

ICD-10- Code

Heather came in today complaining of pain in her lower leg. She did not have any injuries. No swelling or redness.

Pain is worst when standing. She says she has to use her cane to help when standing.

Impression: lower leg pain

729.5 Pain limb

Heather came in today complaining of pain in her right and left lower leg. She did not have any injuries. No swelling or redness.

Pain is worst when standing. She says she has to use her cane to help when standing.

Impression: bilateral lower leg pain

M25.561 pain in right knee

M25.562 pain in left knee

Notice that in both of these examples, with a little more detail in the documentation, accurate diagnosis coding can be achieved.


Having a certified CDI practitioner help build a customized CDI plan for your medical practice will pay for itself long-term with more accurate reimbursement, reduction of risk, and even the possibility of an increase in reimbursement. So, how else can a CDI practitioner help? 

The CDI practitioner can handle and oversee all medical record reviews, provide education and guidance to other practitioners, work with practitioners to assign the appropriate codes (CPT, HCPCS, ICD-10-CM, etc.), and support the services reported and medical necessity. A reliable practitioner can provide up-to-date solutions and feedback on the current CDI program. While the success of such a program depends greatly on the capabilities of the local practitioners, choosing the right person to oversee things can set the tone for a successful implementation. This is critical with ICD-10, which is more detailed and in many cases requires modification of clinical documentation. Currently, when  performing an ICD-10 readiness audit and comparing ICD-9-CM coding to ICD-10-CM, I am finding a 15-25 percent error rate, meaning that documentation will not support a specified ICD-10 code 15-25 percent of the time. This means we all have quite a lot of work to do before the ICD-10 implementation date.

When building a CDI program, make certain that you set specific goals. Keep in mind that the overall goal is to improve documentation, coding, and reimbursement. I recommend you begin with these aims in mind when getting started:

  • Aim to establish a well-organized medical practice.
  • Produce reliable medical records that can help enhance the quality of care for patients.
  • Promote the profitability of the provider.
  • Develop a query process to clarify coding and documentation.
  • Provide guidance and direction to providers regarding documentation expectations.
  • Audit and monitor continuously.
  • Stay on top of coding and carrier guidance.

There are three general processes that you also should take into consideration:

  • Assessment
  • Implementation
  • Maintenance

First, let’s break out all of these elements. The assessment is critical in determining the current state of your practice.


  • Evaluate current systems in place for clinical documentation.
  • Conduct a baseline medical record audit to identify areas that may require:
    • Improvement
    • Corrections
  • Make physician education, training, and briefing part of the assessment process.
  • Ensure specific goals and expectations are set for the providers and the practice.
  • Keep types of audits separate:
    • Diagnostic procedures
    • Therapeutic procedures
    • E/M and consultation
    • Focus on level 1-5 visits
  • Don’t just target levels 4 and 5
  • Reimbursement could be missed
  • Review bell curve data and practitioner utilization
  • Use diagnosis coding to support medical necessity and to support ICD-10


  • A CDI provider will collaborate to implement the needed changes in the best way possible, wherein everyone can smoothly adjust.
  • Everyone should be made aware of the importance of every task.
  • Pre planning is the initial step in which everything needed (tools, work spaces, personnel, templates, etc.) is prepared for successful implementation.
  • A customized program also should be developed, based on the results of the audit.
  • The necessary education should be provided to local practitioners in preparation for the maintenance or sustaining process.
  • Based on the suggestions of a well-planned audit, needed changes should be implemented while every move is closely monitored by a dedicated staff.
  • The effectiveness of the CDI tasks should be evaluated to identify areas that may require further improvements or evaluations.


Queries, a valuable aspect of CDI, also should be part of CDI implementation. A query is a question posed to the physician to obtain additional clarifying documentation in order to assign a procedure or diagnosis code. Query responses can be documented in the progress note, discharge summary, or in a query form that is kept as part of the permanent record.

Queries must be:

  • Clinically based
  • Fact-driven
  • Concise and to the point
  • Not leading

When to Query

  1. Whenever there is conflicting, ambiguous, or incomplete information.
  2. Regarding any significant procedure, condition, or reportable event.

When not to Query

Queries should not be used to question a provider’s clinical judgment.


Maintaining a CDI program is critical to its success. The program should be maintained by the local practitioners and administrators. To ensure the sustainability of the program, the provider or consultant should stay closely involved with:

  • Monitoring
  • Continuing education
  • Performing additional audits
  • Managing adjustment programs

Let’s look at an example. Let’s say ABC Medical Practice decided to implement a CDI program. In order to assess the current state of coding and documentation, a baseline audit was conducted by reviewing 10 records per practitioner, with results contrasted with the Centers for Medicare & Medicare Services (CMS) bell curve data and each individual practitioner’s utilization. Also, the practice took into consideration over-utilized services such as E/M level 4 and 5 services, along with common diagnoses reported in the practice. 

Once the audit results were completed, it was determined that the providers who fell between 95-100 percent compliance would undergo an annual audit of 10 medical records. Providers who fell between 80-90 percent compliance would be audited based on 5 percent of their total patient encounters per month until 95 percent compliance was reached over a three-month period. Providers who fell between 70-80 percent compliance would have 10 percent of his/her patient encounters audited per month until 95 percent compliance was realized over a three-month period, and providers who fell below 70 percent would be placed on 100 percent review until 95 percent compliance was reached over a three-month period.

All of the providers were provided with education on coding visits, procedures, modifier usage, and diagnosis coding and documentation, with an emphasis on ICD-10 readiness. Physicians who fell under monthly review were provided with one-on-one education on all problem areas.

In addition to developing a query process, every practice must assign a staff person or CDI practitioner to monitor and manage these queries. You also must decide how the queries will be formatted. Will it be done via email, a software-based program, or simply by posting to an intranet site assigned to the practitioner? Once you determine the method of delivery, you must decide how long to hold the queries for response. I recommend you hold them no longer than 7-10 days, as you want to get the claims sent to your insurance carrier, but you do not want to send claims that are not accurate. How do you get the practitioners to respond? The management team must buy into the CDI improvement process, and practitioners should be educated on the process and the rationale behind it. So many times we implement processes within a medical practice without educating everyone and explaining their importance. Management also must support the effort and mandate that practitioners comply. A physician champion is a perfect person to lead the charge and reinforce the importance of a solid CDI program.

The CDI practitioner must monitor the number and types of queries being made per month, by practitioner, to identify providers who might need more help with their coding and documentation. A provider who has three queries per month might need as much help and guidance as the practitioner who has 60 per month. Managing and monitoring your queries will help your practice understand what problem areas of documentation exist and provide validation of training necessary to achieve documentation improvement.


Track results

Remember to monitor improvements and deficiencies. Educate practitioners who fall below accepted standards set by the practice or group. Make sure your compliance plan is active, along with the CDI program, and that both are working/breathing documents.

To overcome CDI challenges, just like with any challenges, it should all start with proper awareness and motivation. In this case, appropriate physician training and clinically oriented education should be provided. Hire a reliable provider of CDI programs who can collaborate with local practitioners effectively. By having a team of specialists who can impart CDI solutions according to expertise, the exact needs of the facility will be matched to the appropriate solutions. Invest in training tools and materials that are needed for documentation. This way, physicians and nurses can document properly.


Take advantage of the services offered by a top-performing CDI specialist to ensure a good connection between coders and physicians. This professional also can bring additional revenue in the form of returns by simply ensuring proper clinical documentation, continuing education through CME-based seminars, and trainings to motivate physicians to perform at their best. A reliable provider of CDI programs prioritizes proper physician education and professional advancement and demonstrates specific and practical benefits to all stakeholders, who include the coders, nurses, administrators, and physicians. This will serve as a motivation to sustain these initiatives.

Allow for sufficient time and resources for queries and arrange schedules so they can be effective in terms of personnel being able to access physicians when needed. Reward practitioners for a job well done. This is important to ensure continuous motivation. As long a CDI program is implemented properly, everything else falls into place. Also, with the help of a reliable CDI practitioner, you can be sure that all tasks are done the right way without wasting time and resources.

A well-planned, thought-out CDI program paired with the implementation of ICD-10 will assist with proper documentation as well as proper rendering of procedures and services,  support of medical necessity to validate the services, and improvements in terms of accurate reimbursement.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner

Deborah Grider has 35 years of industry experience and is a recognized national speaker, consultant, and American Medical Association author who has been working with ICD-10 since 1990 and is the author of Preparing for ICD-10, Making the Transition Manageable, Principles of ICD-10, the ICD-10 Workbook, Medical Record Auditor, and Coding with Modifiers for the AMA. She is a senior healthcare consultant with Karen Zupko & Associates. Deborah is also the 2017 American Health Information Management Association (AHIMA) Literacy Legacy Award recipient. She is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.