The vast majority of hospitals can say they have a clinical documentation integrity (CDI) program. Fewer can say it works as well as it should. Even fewer can say it works consistently across inpatient, facility outpatient and professional/ambulatory care settings.
That gap matters more now than ever because of familiar shifts in how and where care is provided, reimbursed and publicly reported. Healthcare organizations are under relentless pressure to prove not just that they delivered care, but that they delivered care that is complex and of high quality to increasingly sick patients.
CDI sits quietly underneath that. CDI is the act of ensuring that the medical record accurately reflects the patient’s condition, the services provided and the clinical complexity involved. When it works, it supports quality, reimbursement and compliance. When it does not, organizations leave money on the table, absorb avoidable risk and struggle to explain their true quality and value to the public.
At its core, CDI is about ensuring that the medical record reflects reality. Clinicians deliver care and document what they see, assess and treat. CDI specialists and coding teams ensure that documentation is complete, specific and clinically supported so it can be accurately coded and reported.
Some organizations treat CDI as purely a revenue-focused function. But this framing misses the point. Getting the record right is important to receiving accurate payment for the care provided, but it is more importantly about accurately describing the patient in front of you and accurately reflecting the quality of care.
Inpatient CDI remains a critically important focus
Inpatient CDI is where most programs started, and it remains the most mature area for many organizations. There are practical reasons for this. Inpatient care has long driven quality ratings and a significant portion of hospital revenue. The rules are well established, teams are in place and processes are familiar.
As a result, most hospitals have an inpatient CDI program that is, at minimum, functional. More sophisticated hospitals have inpatient programs that effectively integrate people, process and technology to address the low-hanging fruit and to capture more advanced opportunities that require a true “clinical detective” approach.
The challenge is that care has not stayed put. Outpatient services now account for a growing share of encounters, revenue and clinical complexity. Professional services, particularly in employed physician models, carry substantial financial and risk-adjustment implications.
Yet for most organizations, CDI maturity drops sharply outside the inpatient walls. Facility outpatient CDI introduces additional complexity. Documentation must reflect the encounter across a wide range of settings, such as the emergency department, observation, procedural areas and hospital-based clinics. Nursing and ancillary documentation plays a larger role.
Many organizations have either rudimentary outpatient CDI programs or none at all. Others rely on informal processes that vary by department. The result is inconsistent documentation and all that comes with it.
Professional and ambulatory CDI faces a different set of challenges. Historically, physician documentation was evaluated through a coding-heavy lens. Recent changes to evaluation and management rules shifted the focus toward medical decision-making, clinical risk and data complexity. Many organizations are still catching up. High-performing programs help physicians document the clinical story of the encounter, a shift that improves risk adjustment, supports value-based arrangements and more accurately reflects clinicians’ productivity. This is of essential importance when practices employ advanced practice providers such as nurse practitioners working alongside physicians.
What strong CDI programs have in common
Organizations that perform well share several traits, regardless of size or setting:
- They align CDI with organizational strategy. Leadership understands how documentation affects quality ratings, revenue integrity and patient care. CDI is not siloed; it is part of how the organization measures itself.
- They invest in people. Training does not stop after onboarding. CDI specialists, coders and clinicians receive ongoing education and feedback. As rules change and care evolves, programs keep pace.
- They leverage technology. Technology can improve the experience of the caregivers, reduce burden, capture low-hanging fruit, improve workflows and allow the CDI team to focus on higher-level concepts and more advanced opportunities that the technology is not effectively addressing.
- They build disciplined processes. CDI and coding teams work together. Reviews are prioritized based on impact, with clear checkpoints to prevent avoidable misses before claims are finalized.
- They keep the patient at the center. Clear, accurate records support better care coordination and clinical decision-making. That connection matters to clinicians, and strong programs make it explicit. Designers of the strongest programs know that better documentation is about providing the best care possible to patients and accurately reflecting that care.
Hospitals that treat CDI as an organizational competency are better positioned to adapt as care continues to move and payment models evolve. They can explain what happens with confidence and demonstrate the complexity of the patients they serve.
Getting the record right may not be glamorous. It is, however, essential. And in today’s environment, it may be one of the clearest signals of whether an organization truly understands its own performance.
Dana Domabyl, Michelle Fu and Paul Minoff contributed to this article.
What high-performing CDI programs do differently
High-performing CDI programs operate as core capabilities. They focus first on getting the clinical story right, not simply chasing individual codes. They prioritize cases based on impact rather than volume. They tightly coordinate CDI, coding and clinical teams instead of letting work hand off in silos. They use technology to surface signals, then rely on experienced professionals to apply judgment. And they invest in ongoing education, recognizing that documentation rules and clinical practice never stand still.
The result is better reimbursement and clearer insight into patient complexity, outcomes and organizational performance.
Technology helps, but it does not think
As with many aspects of healthcare today, artificial intelligence has a growing role in CDI. Tools that support ambient documentation, flag potential gaps or surface suspect conditions can reduce administrative burden and improve scale.
Used well, technology can be a force multiplier. But used poorly, it becomes a crutch. Many AI tools are good at identifying low-hanging fruit but are less reliable at determining what may be missing from the record or whether a diagnosis is clinically supported in context. Without strong processes and experienced people, organizations risk chasing noise while missing meaningful opportunities.
Technology should support judgment, not replace it. The most effective programs use AI as an input but not as a final decision-maker.
