The Evolutionary Stages of CDI

  • Dr. Terrance Govender
  • April 16th, 2019

The growth of the CDI industry in size as well as in its relevance to the changing landscape of healthcare is clear. Whether you are just entering the industry as an enthusiastic newbie, or an industry veteran, you will agree that CDI has undergone some significant changes over time along the lines of scope, organizational structure and functional stakeholders just to name a few. I like to refer to it as the “evolution” of CDI, since the progression to a more complex form is necessary to support our industry’s increasingly important role in the bigger healthcare picture.

Based on my experience in several roles on the vendor side of the CDI industry, I have been able to take a step back and categorize the changes I have witnessed at many organizations, as well as describe the changes necessary for our industry to deliver sustained value in healthcare into three “stages”:

I have outlined the stages of progression below. As you read them, you may identify your program as falling within the limits of a specific stage. However, it is also likely that your program will span multiple stages due to its complexity and level of sophistication.

Stage 1: Optimize that DRG!

Optimizing the DRG is probably the driving force not only behind the inception of CDI, but also its exponential growth since the introduction of MS-DRGs. While the words used to describe this purpose may depend on who you are talking to, the goal is essentially to ensure that the patient is coded to the appropriate DRG group and severity level (e.g., W CC) every single time as appropriate. Not only is this the earliest stage, it is also one which allows CDI to demonstrate its ROI to an organization, justifying the ever- increasing budgets allocated to additional staffing, CDI technologies, consulting engagements, provider education, etc. Essentially, since the beginning, the value of a CDI program was easily demonstrated, even if the scope was limited to this stage. Furthermore, because the sole focus of “early CDI” was optimizing the DRG, CDI needed only a baseline level of involvement/engagement from providers in order to be successful. This stage was CDI and HIM “heavy”, with queries being generated, both concurrently and retrospectively, and the only action required from the physician being to answer the query based on the clinical evidence already in the medical record. You didn’t even need to have ALL of the queries answered in order to demonstrate significant value of CDI to the organization.

Stage 2: The Breadth and Depth of Severity Documentation

In stage 2, progressive organizations have realized that there is also immeasurable value in capturing the full depth and breadth of patient severity, beyond achieving appropriate DRG shifts alone. These can include the effects of SOI, ROM, HCCs, Value Based Purchasing comorbidities, Vizient Risk Factors, etc. It is at this point, I believe, that we start to realize that perhaps we started off on the wrong foot with physicians due to our approach to CDI in Stage 1 (minimal physician involvement and accountability). However, stage 2 calls for greater physician participation due to the risk of the dreaded “query fatigue syndrome.” More eyes on the charts inevitably means more queries per case, increasing the probability of unanswered queries. To this day, will stop the query process and further review of the chart once they have achieved the highest severity DRG, ignoring that there may be other high severity diagnoses that need documentation and clarification. It is at this stage that we start to better grasp the physician engagement level in CDI at our organization, since a higher level of physician participation is crucial to be successful.

Stage 3: High Documentation Quality Culture

This is in my mind, the “Nirvana” stage. It references an organization where the providers have developed an ownership mentality of the quality of their clinical documentation (as most do with patient care). They feel a sense of accountability and want to be high performers. Most forward-thinking CDI functions should be striving to be in Stage 3. While not easy to attain due to factors like the share of employed versus non-employed physicians and the disparity between professional fee reimbursement and hospital reimbursement, it is most definitely attainable, as by the culture around documentation instilled at a few leading organizations. In this stage, we should essentially see a drop in the query rates for some of the common DRG shifting conditions such as Encephalopathy while high performance on CDI metrics is sustained if not improved. The CDI program, specifically the query process, in this stage of progression, is utilized by the physician as a safety net, and not as a crutch.

I’m sure that you can now appreciate my comment about specific areas of your program being in different stages. I would venture to say, that groups of physicians within a specific specialty group at your facility may fall into different stages as outlined above. Where does your program lie predominantly? What are your goals to progress to the next stage? Do you have a vision for your organization’s CDI function? I hope so. If you’re not growing, you’re dying, and remember:

“It’s not the strongest of species that survives, not the most intelligent, but the one most responsive to change”

-Charles Darwin

The ClinIntell Solution: ClinIntell is the only CDI data analytics firm in the industry that is able to assess documentation quality at the health system, hospital, specialty and provider levels over time. ClinIntell’s clients can monitor sustainability by assessing performance at all of the above-mentioned levels through Documentation Score (accuracy of DRG severity assignments). ClinIntell’s clinical condition analytics assists its clients in identifying gaps in the documentation of high severity diagnoses specific to their patient mix, ensuring the breadth and depth of severity reporting beyond Stage 1. Accountability and an ownership mentality is promoted by the ability to share peer-to-peer documentation performance comparisons and physician-specific areas of improvement.


Dr. Terrance Govender
VP of Medical Affairs, ClinIntell, Inc.