CDI-Clinical Documentation Improvement Audit

When a CDI audit is in a facility’s future, several factors should be considered for a smooth and successful outcome.

The first consideration is the end goal. Is the facility looking to a launch a future CDI program, where the goal would be reviewing the record to identify missed opportunities between the documentation in the medical record and the allowable codes per the Official Guidelines for Coding and Reporting, or do they have a current CDI program in place and looking at the possibility to expand the program or the possibility to identify missed opportunities?

If the facility is looking to launch a new CDI program, an audit could reveal opportunities that would support a CDI program by identifying gaps, or opportunities between the documentation in the medical record and the allowable codes.

If a facility already has a CDI program in place, the identified gaps could indicate the need for additional resources, or supplementary training and education for existing staff members. Another facet of the established CDI program audit is the review of the query process, including posted queries. The industry standard is the ACDIS/AHIMA Practice Brief titled Guidelines for Achieving a Compliant Query Practice (2019 Update), and as such, not abiding by the Practice Brief could have legal consequences if a query is determined to be leading. It would be in the facility’s best interest to have a review and evaluation of the query process and posted queries.

Another consideration is to identify all facility-specific guidelines that may be in place. While it is not unusual to implement certain procedures to allow the CDI team to function effectively while remaining true to the goals of the program, any data gathered without identification of all facility-specific guidelines related to record review and query development could be flawed and lead to inaccurate decisions.

Examples of facility-specific guidelines that are necessary to identify prior to an audit are a limit to the number and/or type of queries. For a variety of reasons, facilities often find it necessary to limit the queries either by payer, or optimization of the DRG (Diagnosis Related Group) or SOI/ROM (Severity of Illness/Risk of Mortality). Another example is because there are often small differences in the thresholds from lab to lab, facilities may find it necessary to place a cut-off lab value where the CDI professional is obligated to develop a query or not. Lastly, but not exhaustive, there may be restrictions on the number of relevant clinical indicators and/or options that are included on a query.

A final consideration, albeit the first thing that is necessary for every auditor/reviewer to note is the date and time the CDI professional last reviewed the record, which is often found in the CDI software. Additionally, noting whether the CDI professional is required to review the medical record after the patient is discharged is an important factor. Both of these are integral to a successful audit because a CDI professional is not responsible for any documentation that was placed after they last reviewed the patient’s record, regardless whether that date and time was concurrent or retrospective.

A comprehensive audit is imperative for a CDI program’s success. We have the workforce solutions to assist with all of your audit needs to ensure a successful outcome.


Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP, CCDS-O

Mid-Revenue Cycle CDI Content Manager