CDI….. Clinical Documentation Improvement or Clinical Documentation Integrity or both?

The term ‘Clinical Documentation Improvement’ has been around for many years and described the early work of the reasoning behind the program’s start. The early implementation of CDI programs were sold to CFOs (Chief Financial Officers) as a way to increase their revenue stream around opportunities that were being left on the table by providers. The clinicians were not documenting in the diagnostic terms needed by the coding staff who were applying ICD-9 codes, which then drove to a DRG (Diagnostic Related Group) that was used by CMS to decide on the amount of payment for that patient’s hospitalization.
Now we have the MS-DRG system and the APR-DRG system, as well as CORE measures, RAC (Recovery Auditor Contractors) audits, pre-bill audits, Pepper Report Data, and ICD-10 on the horizon, which are all drivers of the importance of not only improving the documentation but making sure that its integrity is standing up to all of these outside forces.
Now Integrity seems to be a more descriptive word for the work of the Clinical Documentation Specialist (CDS), as they must work to make sure that the correct SOI (Severity of Illness), ROM (Risk of Mortality), as well as the accurate reflection of utilization of resources (MS-DRG) are all illustrated by the provider documentation. It is so important that the whole picture of the patient’s stay is reflected and appropriately portrayed by the codes applied; in order to make sure that it can withstand all of the quality audits (PSI-Patient Safety Indicators, HAC-Hospital Acquired Conditions), billing audits and compliance audits. Clinical Documentation Integrity seems to better portray all of the work around the bigger picture (above & beyond revenue) that the CDS of today are required to understand and apply to their day-to-day work.

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