Clinical Documentation Improvement (CDI) Program Support
MedCodex provides comprehensive CDI program support to help hospitals and health systems improve the accuracy, completeness, and specificity of clinical documentation. Our CDI specialists work concurrently and retrospectively to ensure that physician documentation fully reflects patient acuity, supporting accurate DRG assignment and optimal case mix index (CMI).
What Our CDI Program Covers
- Concurrent medical record review during patient stay
- Retrospective review of discharged records
- Physician query generation and tracking
- DRG optimization and CMI improvement
- CC/MCC identification and documentation gap analysis
- Mortality and severity of illness review
Concurrent CDI Review
Our CDI specialists review inpatient records within 24–48 hours of admission, identifying documentation deficiencies that could impact DRG assignment. Timely queries during the patient stay yield higher response rates and more accurate coding at discharge.
Retrospective CDI Review
For records that were not reviewed concurrently, our retrospective CDI team analyzes coded records post-discharge to identify missed diagnoses, incorrect principal diagnosis selection, and undercaptured CCs/MCCs. Findings are reported to both the CDI and coding teams for process improvement.
Physician Engagement
Successful CDI programs require physician buy-in. MedCodex assists with physician education, feedback reports, and query response tracking to help build a culture of documentation excellence. Our queries are always compliant, non-leading, and aligned with AHIMA and ACDIS guidelines.
Program Metrics & Reporting
We provide detailed monthly CDI performance reports including:
- Query volume, response rate, and agreement rate
- CMI trend analysis and DRG impact
- CC/MCC capture rate improvements
- Physician-level performance benchmarking
- Revenue impact analysis