Clinical documentation refers to how physicians and other healthcare clinicians record the medical information and diagnoses of their patients in the medical record. Inadequate clinical documentation has many adverse consequences: inadequate communication among healthcare providers, suboptimal patient care, false quality of care reports, inaccurate healthcare data quality, improper payments to healthcare providers and hospitals. Clinical documentation improvement programs help to correct these deficiencies.

Clinical documentation improvement or integrity (CDI) are synonyms for the process of concurrently reviewing medical record documentation to ensure the completeness and accuracy of medical records. Bridging the gap between clinical documentation and accurate coding drives CDI programs. A CDI program includes a review of medical records by trained specialists for documented diagnoses and other clinical information, and what documentation might be missing. These clinical documentation specialists then ask physicians to document additional information and diagnoses so the medical record can be correctly coded and the proper DRG assigned to accurately reflect the full picture of a patient’s medical condition.

Diagnostic related groups (DRGs) are inpatient classification schemes that categorize patients who share similar clinical characteristics and costs. A DRG is based on the ICD-10 codes on the hospital billing claim. Several DRG systems have been developed, each with its own characteristics and methodology. Two widely-used DRG systems are MS-DRGs (Medicare Severity)—used by Medicare and many commercial payers, and APR-DRGs (All Patient Refined)—used by many state Medicaid programs.

Each year, every DRG is assigned a unique fixed value (called “relative weight”) applicable to all hospitals and used in calculating the reimbursement for all services provided during an inpatient admission. A hospital-specific reimbursement rate is assigned to each hospital based on its costs associated with its particular patient population. The DRG payment is calculated by multiplying the relative weight for the DRG by the hospital’s reimbursement rate.

Example:
MS-DRG 293 – Heart Failure
Relative Weight (RW) 0.653
X Hospital Blended Rate $6,000
= MS-DRG Payment $3,932

There are several components of CDI performed by clinical documentation specialists (CDS) including the following:
- Selection of medical records to be reviewed.
- Review of medical records to identify a working principal diagnosis, significant procedures, and pertinent comorbid diagnoses to establish a working DRG.
- Identification of additional diagnoses and procedures that may not yet have been properly documented for correct coding and that may affect the final DRG.
- Submitting clarification questions (“queries”) to clinicians caring for a patient to obtain additional needed documentation.
- Follow-up of unanswered, when necessary
- Verification that all pertinent diagnoses affecting the DRG are supporting by clinical findings in the medical record.
- Collaborate with coding colleagues to ensure that the final CDS DRG matches the finalize coder DRG for claim submission.
- Keeping succinct notes of all findings and actions.

According to Medicare regulations:

- “Clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record.”
- “The purpose of DRG [clinical] validation is to ensure that diagnostic and procedural information…coded and reported by the hospital on its claims matches the attending physician’s description and the information contained in the medical record.”

The consequences of submitting clinically invalid diagnoses are numerous and can be severe: improper DRG reimbursement, excessive denials, unnecessary appeals, risk of regulatory audits and penalties