The process of checking medical record documentation for correctness and completeness is known as clinical documentation improvement, or CDI. A evaluation of the disease process, diagnostic results, and any gaps in the documentation are all included in CDI. A CDI specialist frequently has experience with both clinical and medical coding. The goal of CDI programmes is to close the gap between accurate coding and clinical documentation.

Although a patient’s medical record may also contain reports from diagnostic tests, laboratory tests, and specialist consultations, “clinical documentation” in the context of CDI typically refers to the notes made by a clinician or clinical staff member who is in charge of the patient’s care during an in-person visit.

Healthcare has included CDI programmes long before the phrase was coined. But when the Centres for Medicare & Medicaid Services (CMS) introduced Medicare Severity Diagnosis Related Groups (MS-DRGs) in 2007, their appeal increased. Medicare’s Inpatient Prospective Payment System (IPPS) uses the MS-DRG payment model for compensation. Hospitals discovered that complete and correct diagnosis code reporting lowered IPPS compliance risks and enhanced reimbursement. Consequently, CDI programmes were set up so that a group of nurses may simultaneously examine the paperwork from the inpatient medical records and ask a provider about anything unclear or incomplete before filing a claim. The facility’s billing became more accurate as a result of this practise, and the CDI trend gained traction.

Although CDI may have originated in the inpatient setting, outpatient providers have also begun to recognise the benefits and have launched programmes. While inpatient and outpatient CDI programmes have different structures, they all aim to improve the quality of clinical documentation and coding.