Throughout my career, I’ve been deeply immersed in the world of clinical documentation integrity (CDI)—as a consultant for healthcare organizations, an advocate for the critical value the CDI process can bring, and for the past 18 years, as author of the CDI Pocket Guide® with Dr. Richard Pinson.
Today, I feel more concerned—and frankly, more frustrated—about the direction of CDI than ever before. It’s time we return to the basics: foundational ethics and the core mission of CDI—ensuring accurate, complete documentation that supports appropriate coding and reimbursement.
In too many organizations, CDI has lost its way. Instead of focusing on addressing documentation gaps that directly impact DRG assignment and reimbursement, excessive time and resources are being spent on chasing missing but useless information.
One of the most troubling consequences of this shift is the unnecessary burden placed on providers. Physicians, surgeons, and other clinicians are inundated with queries—many of which are unwarranted—spending hours we all should prefer they spend providing care to patients (and billable services).
Here are some examples of misguided CDI practices that highlight the need for change:
In some organizations, exhaustive reviews are conducted for every unintended puncture or laceration during surgery due to a misplaced fear of impacting hospital quality scores. However, these codes may only affect quality measures when a secondary procedure is performed days later—a rare occurrence that’s easy to identify. Despite this, surgeons are repeatedly queried to confirm whether these incidents are inherent to the procedure or clinically significant—perhaps hoping to avoid coding it.
Querying providers for greater specificity is not necessary simply because a more specific code exists. Providers being asked to specify “chronic” systolic or diastolic heart failure is unnecessary when such detail isn’t relevant (when non-acute) nor required for DRG assignment. Similarly, providers are queried to distinguish between viral, bacterial, or fungal pneumonia based on treatment, even when the additional specificity has no effect on DRG assignment—simply because some believe that a patient should “never” be hospitalized for a “simple” pneumonia.
These queries waste valuable time and do little to improve the quality of documentation or patient care.
The idea that every diagnosis must be further specified, every possible secondary diagnosis queried, or every complication code avoided is counterproductive. This scattershot approach not only overwhelms providers but also dilutes the focus on truly impactful documentation. Worse, it risks alienating providers, undermining the collaboration essential to a successful CDI program.
Improving documentation is critical—but it must be meaningful. Querying for every detail, regardless of its impact, wastes time and resources that could be better spent elsewhere.
As we move forward, I urge CDI specialists, coding professionals, and everyone involved in the documentation process to focus on what truly matters. Let’s tackle the work that makes a real difference for our patients and our organizations, leaving behind activities that offer little value.
There’s too much good we can and should be doing. Let’s not squander it on tasks that don’t move the needle.
My hope for the future? That we all recommit to CDI’s core purpose and refocus our efforts where they matter most.
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