The CDI leader's keys to success: Solid partnerships, driving improvements

Clinical documentation improvement (CDI) programs are prevalent in many hospitals and have evolved over the years. In 2014, 66% of 318 hospitals surveyed by AHIMA had a CDI program in place. If all surveyed facilities that planned to implement a CDI program did so, 80% of responding hospitals would have one. These numbers are likely even higher today as CDI programs become ever more relevant.

CDI programs can be a valuable bridge between clinical care and coding at hospitals. By concurrently reviewing clinical documentation in medical records and ­conferring with and educating providers, CDI teams continually support accurate documentation. When CDI program staff collaborate with providers and coders around improved documentation, the result is more accurate coding, reporting, quality metrics, and reimbursement.

Greater detail in clinical documentation is required since the introduction of ICD-10, making CDI efforts even more relevant. In addition, healthcare is steadily moving toward value-based purchasing and greater scrutiny from regulators and the public. With all of this in mind, it is more important than ever to get documentation and coding right. The daily activities surrounding CDI are crucial to successful outcomes and sustainability of facilities and healthcare systems.

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