CDI Reporting Structure- Optimizing Outcomes

Clinical Documentation Integrity (CDI) should not report to Health Information Management (HIM) because their roles, while complementary, have distinct functions and objectives that can conflict or limit their effectiveness if managed under one umbrella. Here are key reasons why CDI should be separate from HIM:

1. Different Focus Areas

• CDI's Focus: CDI primarily works to improve the quality, accuracy, and completeness of clinical documentation in the medical record. This directly impacts coding, billing, quality reporting, and patient care. CDI professionals collaborate closely with physicians and other healthcare providers to clarify documentation and ensure that diagnoses and procedures are correctly represented. Additional CDI duties and responsibilities include collaborating with physicians, physician advisors and Case Management/Utilization Review staff to identify and address any documentation insufficiencies or conflicting documentation that potentially impact payer determination of level of care, inpatient versus observation.

• HIM's Focus: HIM manages patient records, ensuring compliance with legal and regulatory requirements, confidentiality, and proper record retention. They are also responsible for coding and health information management practices but generally focus on the operational and legal aspects of documentation.

2. Distinct Goals

• CDI's Goal: CDI aims to enhance documentation to reflect the true clinical picture of a patient’s condition and care. This often involves ensuring that documentation supports the clinical severity, risk of mortality, and medical necessity while minimizing medico-legal risk. CDI seeks to enhance the completeness and accuracy of the medical record, recognizing that the medical record serves as a communication tool on behalf of the patient, other physicians, and relevant healthcare stakeholders. A byproduct of solid documentation that reflects the telling of the patient story with a reader catching introduction with a tell tailing body and robust conclusion generates accurate compliant optimal coding less prone to payer clinical validation denials and DRG downgrades, both extremely costly requiring appeals and rework with no assurance of payer overturn.

• HIM's Goal: HIM typically focuses on compliance, recordkeeping, and coding. While they may support the coding and reimbursement process, their main goal is ensuring proper documentation from a legal and administrative perspective.

3. Collaboration vs. Oversight

• CDI professionals need to work collaboratively with clinicians to ensure the documentation reflects the true clinical picture. Reporting to HIM may create a hierarchical structure that could discourage this collaborative, consultative approach.

• If CDI reports to HIM, there may be a focus more on the administrative and operational side of documentation, which could reduce the focus on clinical accuracy and collaboration with healthcare providers. Association with HIM increases the tendencies to assimilate CDI with coding, contributing to and accentuating the physician’s belief that CDI is all about coding and hospital reimbursement.

4. Conflicting Objectives

• CDI professionals often work directly with physicians to clarify and round out documentation with the critical capture of the physician’s clinical judgment and medical decision making, fundamental to the practice of medicine.

• HIM might view CDI as an external entity interfering with their established processes, potentially creating tension between the departments. This does not preclude congenial two way communication between both parties, both disciplines working together to ensure the medical record adequately supports optimal compliant coding less apt to be second guessed by payers and their contractors who conduct coding audits used to reduce provider reimbursement and increase profits to the C-suite and their shareholders.

5. Maintaining Independence for Clinical Accuracy

• For CDI to be most effective, it needs to maintain independence from the administrative and compliance functions of HIM. Reporting separately allows CDI to have a clear focus on improving clinical documentation without being constrained by HIM’s regulatory, administrative priorities, and focus on coding and bill hold.

6. Professional Expertise

• CDI specialists often come from clinical backgrounds (such as nursing or foreign medical graduates or other clinical discipline), while HIM professionals typically come from an administrative or coding background. Their expertise in different areas means they may approach issues from different perspectives, and each department needs to function autonomously with overlap and support as needed to optimize its effectiveness, operating at the top of their game.

7. Separation of Clinical and Administrative Functions

• To maintain a clear division of responsibilities, CDI should report to clinical leadership (such as the Chief Medical Officer or a clinical director) rather than administrative leadership. This ensures that CDI has the clinical authority to engage physicians directly in improving documentation without being seen as part of the administrative oversight system.

8. Promoting Continuous Improvement

• CDI requires a continuous, dynamic approach to documentation improvement that often includes direct feedback to providers on clinical documentation. Having CDI report to HIM may create a perception that the role is more about compliance, coding, and reimbursement than improvement, thus stifling innovation and a culture of continuous improvement.

In summary, separating CDI from HIM ensures that each team can focus on its specialized role—CDI on improving clinical documentation and HIM on managing records and coding compliance. This structure promotes better collaboration, enhances the quality of documentation, and avoids potential conflicts between the clinical and administrative aspects of healthcare documentation. In short, an effective CDI program structured and poised to produce sustainable measurable optimal performance requires reporting dynamics consisting of Chief Medical Office, Utilization Review Director, or Physician Advisor versus Health Information Management.