Clinical Documentation Improvement (CDI) Services
Reimbursement is calculated from codes, and codes are only as specific as the chart behind them. MedPrecision's CDI team reviews records concurrently and retrospectively, issues AHIMA-ACDIS-compliant physician queries, and validates the MS-DRG, CC/MCC, Present on Admission, and HCC risk-adjustment capture that decides both what you are paid and how sick your data says your patients were.
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What Are Clinical Documentation Improvement (CDI) Services?
Clinical documentation improvement (CDI) services review the medical record -- concurrently while the patient is in-house and retrospectively before the bill drops -- to make sure every diagnosis is documented specifically enough to code accurately. When the note is ambiguous or incomplete, a CDI specialist issues a compliant physician query following the AHIMA-ACDIS Guidelines for Achieving a Compliant Query Practice (2022 Update). Accurate documentation drives the MS-DRG assignment, the capture of complications and comorbidities (CC/MCC), the Present on Admission (POA) indicators required under the Deficit Reduction Act of 2005, and -- in the outpatient and Medicare Advantage setting -- the HCC codes that set the RAF risk score. For FY 2025 there are 773 MS-DRGs, and a case's group is determined by its principal diagnosis, secondary diagnoses, procedures, sex, and discharge status.
- Concurrent and retrospective/pre-bill chart review across inpatient and outpatient settings
- AHIMA-ACDIS-compliant, non-leading physician queries (open-ended, multiple-choice, yes/no/POA)
- MS-DRG, CC/MCC, and Present on Admission (POA) validation for accurate severity capture
- HCC and RAF-score review for Medicare Advantage and value-based risk adjustment
Clinical documentation improvement (CDI) is the discipline of making the medical record say, in codeable terms, exactly how sick the patient was and how much work their care required. It is not coding and it is not utilization review -- it sits between the clinician's note and the claim, closing the gap between what the physician knows and what the documentation actually supports. MedPrecision's CDI team reviews charts both concurrently and retrospectively, issues AHIMA-ACDIS-compliant physician queries when the record is ambiguous or incomplete, and validates the MS-DRG assignment, CC/MCC capture, Present on Admission (POA) indicators, and HCC risk-adjustment codes that determine both reimbursement and quality scores. Because the ICD-10-CM diagnosis codes that drive severity are only as specific as the words in the chart, a single unclarified diagnosis can move a case across an MS-DRG boundary or drop a Hierarchical Condition Category entirely. We work the inpatient DRG side and the outpatient HCC side, because -- per the CMS MLN health care code sets guidance -- ICD-10-CM diagnosis codes appear on all inpatient and outpatient claims, and documentation quality follows them into both settings.
Who This Service Is For
The State of Clinical Documentation Improvement (CDI) Services in 2026
Clinical documentation improvement exists because reimbursement is calculated from codes, and codes are only as specific as the documentation behind them. On the inpatient side, CMS pays IPPS hospitals under the MS-DRG system -- 773 MS-DRGs for FY 2025 -- where a case is grouped by its principal diagnosis, secondary diagnoses, procedures, sex, and discharge status, and where each ICD-10-CM code is weighted as an MCC, CC, or NonCC based on its effect on resource use. A hospital's Case Mix Index -- the average DRG relative weight across its Medicare discharges, calculated by summing the DRG weights and dividing by the number of discharges -- is the aggregate expression of how well that severity is captured. The FY 2025 operating payment update for hospitals meeting the Hospital IQR and meaningful-EHR-use requirements is +2.9% (a 3.4% market-basket increase reduced by a 0.5-point productivity adjustment, per the CMS FY 2025 IPPS Final Rule), and that rate is applied to whatever DRG the documentation supports -- which is why the documentation itself is the leverage point. The frontier is now outpatient: the 2024 CMS-HCC risk-adjustment model, fully ICD-10-based, reaches 100% of Part C risk-score weighting in CY 2026, pushing the same documentation discipline into the clinic where chronic-condition specificity sets the RAF score. Across both settings, the governing rulebook for closing documentation gaps is the AHIMA-ACDIS Guidelines for Achieving a Compliant Query Practice, which sets the non-leading standard every query must meet.
What Is Breaking Right Now
Secondary diagnoses that were clinically present but never documented specifically enough to code as a CC or MCC
MS-DRG assignments that understate severity because an ambiguous note was never queried
Present on Admission indicators reported incorrectly, causing Hospital-Acquired Conditions to be disregarded as CC/MCC
HCC and RAF gaps where a chronic condition was managed but not documented to the ICD-10 specificity risk adjustment requires
Leading or non-compliant queries that create audit exposure instead of defensible documentation
Common Clinical Documentation Improvement (CDI) Services Mistakes to Avoid
Writing leading queries that hand the provider the answer
A query that discloses the reimbursement or quality impact, or that offers only the 'right' diagnosis, is non-compliant under the AHIMA-ACDIS 2022 standard and turns a legitimate clarification into audit exposure.
Hold every query to the non-leading test before it reaches a provider: a neutral statement, clinical indicators pulled from the record, and clinically valid options -- including 'other' on multiple-choice and 'unable to determine' on POA/yes-no queries.
Treating a verbal clarification as if it were documented
A response to a verbal query is not codeable unless the provider records it in the permanent health record, so a hallway agreement that never reaches the chart adds nothing and cannot be coded.
Close the loop in writing: confirm the provider's clarification appears in the permanent record before the diagnosis is coded, consistent with the AHIMA-ACDIS guidance.
Assigning POA indicators without confirming timing
A Hospital-Acquired Condition mistakenly reported POA=Y can misstate quality data, while a genuinely present condition reported POA=N is disregarded as a CC/MCC and drops the MS-DRG payment (per CMS).
Review POA against the admission-order timeline for the principal and every secondary diagnosis, using the correct value (Y, N, U, W, or 1) -- and never apply the '1' exempt indicator to a code on the HAC list.
Capturing a CC/MCC without checking the CC Exclusion List
Some CC/MCC secondary diagnoses do not raise severity when they are closely related to the principal diagnosis, so assuming every captured CC lifts the DRG overstates expected reimbursement and invites downgrade denials.
Validate each secondary diagnosis against the CC Exclusion List during coding reconciliation, so the working and final MS-DRG reflect only the severity the rules actually credit.
What We Handle
Concurrent & Retrospective Chart Review
We review records concurrently -- while the patient is still in-house, when the physician can still add or clarify a note -- and retrospectively before the bill drops, checking that every reportable diagnosis is documented to the specificity ICD-10-CM requires. Because ICD-10-CM diagnosis codes appear on all inpatient and outpatient claims and reflect the reason the patient sought care (per CMS), both settings are in scope.
AHIMA-ACDIS Compliant Physician Queries
When the record is ambiguous, conflicting, or missing a diagnosis the clinical indicators support, we issue a physician query built to the AHIMA-ACDIS Guidelines for Achieving a Compliant Query Practice (2022 Update): a non-leading statement, clinical indicators drawn from the record and included in the query, and a title that carries no reimbursement, quality, or desired-response cues. Queries use the open-ended, multiple-choice, or yes/no (POA) format the clinical question calls for.
MS-DRG & CC/MCC Capture Validation
Every ICD-10-CM code is classified by CMS as an MCC, a CC, or a NonCC based on how much its presence as a secondary diagnosis raises hospital resource use. We validate that the working and final MS-DRG reflect the documented severity, and we check each secondary diagnosis against the CC Exclusion List so closely related conditions are not assumed to raise severity when the rules say they cannot.
Present on Admission (POA) Review
Under the Deficit Reduction Act of 2005, IPPS hospitals must report a Present on Admission indicator on the principal and every secondary diagnosis. We review the five POA values -- Y, N, U, W, and 1 (exempt) -- for accuracy, because a Hospital-Acquired Condition reported POA=N is disregarded as a CC or MCC and will not raise the MS-DRG payment (per CMS), while the same condition reported POA=Y still can.
HCC Risk Adjustment & RAF Review
For Medicare Advantage, ACO, and value-based populations, we review outpatient documentation for the chronic conditions that map to CMS-HCC categories and drive the RAF score. The 2024 CMS-HCC model is fully ICD-10-based and, per CMS's 2026 Advance Notice, reaches 100% of Part C risk-score weighting in CY 2026 -- so documentation specificity in the clinic now carries the full risk-adjustment impact.
Query Compliance & QA Audit
A leading query is a compliance liability, not a revenue win. Before any query reaches a provider, it passes an internal QA check against the AHIMA-ACDIS non-leading standard -- verifying the statement, the clinical indicators, and the answer options, including the required 'unable to determine' option on POA and yes/no queries and the required 'other' option on multiple-choice queries.
DRG Denial & Downgrade Appeal Support
When a payer downgrades a DRG or challenges a CC/MCC, we assemble the clinical-indicator support from the record and respond. The same documentation discipline that prevents the denial is what defends the DRG on appeal -- so severity that was correctly captured is not quietly conceded on review.
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See What Your Documentation Is Leaving Uncaptured
Send us a sample of finalized inpatient charts and their MS-DRG assignments. We will show you where the documentation supports a CC or MCC that was never captured, where POA indicators are misreported, and which chronic conditions your outpatient notes are dropping before they ever reach an HCC.
Our Clinical Documentation Improvement (CDI) Services Methodology
Concurrent-First Review
We read the chart while the patient is still admitted, when the physician can still add or clarify a note -- not weeks later when a correction means a late addendum. Concurrent review is what lets a documentation gap become a same-stay clarification instead of a post-bill DRG dispute.
Compliant, Non-Leading Queries
Every query follows the AHIMA-ACDIS Guidelines for Achieving a Compliant Query Practice (2022 Update): a neutral statement, clinical indicators drawn from and included in the record, a non-leading title, and clinically valid answer options. The format -- open-ended, multiple-choice, or yes/no (POA) -- is chosen to fit the clinical question, not to steer the answer.
Severity Validation, Not Assumption
Capturing a CC or MCC is only half the work. We validate each secondary diagnosis against the CC Exclusion List and reconcile the working and final MS-DRG, so the severity we report is the severity the rules actually credit -- and can defend if a payer challenges the DRG.
POA Discipline on Every Diagnosis
Because a Hospital-Acquired Condition reported POA=N is disregarded as a CC/MCC, we review POA against the admission-order timeline for the principal and every secondary diagnosis, applying the correct value and keeping the '1' exempt indicator off HAC-list codes.
Documentation as an Upstream Fix
We track the diagnoses that recur as query triggers and feed the pattern back to providers, so the record improves at the source. The goal is fewer queries over time, not more -- a documentation habit change, not an endless clarification queue.
Clinical Documentation Improvement (CDI) Services: MedPrecision vs Alternatives
| Feature | verified MedPrecision | In-House | Other Providers |
|---|---|---|---|
| Chart Review Timing | check_circle Concurrent review while the patient is in-house, plus retrospective/pre-bill, so gaps are caught when the physician can still clarify | Mostly retrospective, after discharge, when clarification requires a late addendum | Review timing varies; often post-bill, after the DRG is already final |
| Query Compliance | check_circle Every query QA'd against the AHIMA-ACDIS 2022 non-leading standard before it reaches a provider | Query quality depends on individual reviewer training; leading queries slip through | Templates used, but non-leading QA is inconsistent |
| MS-DRG / CC-MCC Validation | check_circle Working vs. final DRG validated with CC Exclusion List checks on every secondary diagnosis | CC/MCC capture assumed to lift the DRG without exclusion-list validation | DRG reviewed, but exclusion-list logic often not applied |
| POA Accuracy | check_circle POA reviewed on the principal and all secondary diagnoses against the admission-order timeline (Y/N/U/W/1) | POA defaulted or assigned by coding without a CDI timeline review | POA checked selectively, not on every diagnosis |
| Outpatient / HCC Scope | check_circle CDI extended to outpatient and HCC/RAF review for Medicare Advantage and value-based populations | Inpatient-only; outpatient risk-adjustment gaps go unreviewed | Primarily inpatient DRG focus, with limited HCC coverage |
How the Transition Works
How we deliver clinical documentation improvement (cdi) services for your practice.
Chart Selection & Concurrent Review
We prioritize charts for review -- by DRG, payer, length of stay, or working diagnosis -- and read the record concurrently while the patient is still admitted, when the physician can still add or clarify a note. ICD-10-CM specificity, secondary-diagnosis capture, and POA status are all checked at this stage rather than after discharge.
Compliant Query & Clarification
Where documentation is ambiguous, conflicting, or missing a diagnosis the clinical indicators support, we issue a physician query to the AHIMA-ACDIS 2022 standard. A response to a verbal query is only codeable once the provider documents it in the permanent health record, so we confirm the clarification lands in the chart, not just the conversation.
Coding Reconciliation & DRG Validation
The clarified record is reconciled with coding: we validate the working versus final MS-DRG, confirm each captured CC/MCC survives the CC Exclusion List, and verify POA indicators on the principal and every secondary diagnosis before the claim is finalized.
Metrics, Feedback & Provider Education
We track query patterns and the diagnoses that recur as documentation gaps, then feed them back to providers -- so the same unclarified condition stops generating queries and the record improves upstream. The goal is fewer queries over time, not a permanent clarification queue.
What Reporting and Visibility Looks Like
Transparency is built into every engagement. You will always know where your revenue stands and what actions are being taken on your behalf.
Monthly KPI Dashboards
Track collection rates, denial trends, days in A/R, and payer-level performance with dashboards delivered on a fixed schedule.
Real-Time Claim Tracking
See claim status updates in real time so you never have to wonder where a payment stands or when follow-up is happening.
Quarterly Business Reviews
Detailed reviews with actionable recommendations covering denial root causes, payer trends, and revenue recovery opportunities.
Proactive Alerts
Automated alerts when key metrics shift, so issues are caught and addressed before they affect your bottom line.
Clinical Documentation Improvement (CDI) Services Key Terms
- Clinical Documentation Improvement (CDI)
- The process of reviewing the medical record -- concurrently and retrospectively -- to ensure diagnoses and conditions are documented specifically and completely enough to code accurately, using compliant physician queries to resolve ambiguity. Also called clinical documentation integrity.
- Physician Query
- A compliant request to a provider to clarify ambiguous, conflicting, or incomplete documentation. Under the AHIMA-ACDIS 2022 guidelines it must be non-leading and supported by clinical indicators from the record, and may be open-ended, multiple-choice, or yes/no (POA) in format.
- MS-DRG (Medicare Severity Diagnosis-Related Group)
- The CMS inpatient payment classification -- 773 groups for FY 2025 -- that assigns each case a relative weight based on principal diagnosis, secondary diagnoses (CC/MCC), procedures, sex, and discharge status. Cases are grouped within Major Diagnostic Categories by the MS-DRG GROUPER.
- CC / MCC
- Complication or Comorbidity (CC) and Major Complication or Comorbidity (MCC): the CMS classification of an ICD-10-CM secondary diagnosis by how much its presence raises hospital resource use. Capturing a documented CC or MCC can move a case to a higher-weighted MS-DRG, subject to the CC Exclusion List.
- Present on Admission (POA) Indicator
- A code required under the Deficit Reduction Act of 2005 on the principal and every secondary diagnosis for IPPS discharges, identifying whether a condition was present at the time of the inpatient admission order. Values are Y, N, U, W, and 1 (exempt).
Common Questions
Common questions about clinical documentation improvement (cdi) services.
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Get a Free Billing Audit arrow_forwardWhat is the difference between clinical documentation improvement and medical coding?
Coding assigns the ICD-10-CM, ICD-10-PCS, and CPT/HCPCS codes to what the record already says; clinical documentation improvement makes sure the record says enough to code accurately in the first place. A coder cannot code a diagnosis the physician never documented and cannot infer severity the note does not support. CDI works upstream -- ideally concurrently, while the patient is in-house -- reading the clinical picture and, where the documentation is ambiguous or a supported diagnosis is missing, issuing a compliant query to the provider. The two functions are complementary: strong CDI gives the coder a complete, specific record, and accurate coding turns that record into a correct claim.
What makes a physician query compliant?
Per the AHIMA-ACDIS Guidelines for Achieving a Compliant Query Practice (2022 Update) -- the joint AHIMA/ACDIS practice brief that supersedes all prior versions and applies across inpatient and outpatient settings -- a compliant query must include a clear, concise, non-leading statement (for example, 'please clarify the diagnosis'), and any diagnosis it asks the provider to consider must be supported by clinical indicators taken from the record and included in the query itself. The query title providers see must also be non-leading: it cannot reference reimbursement, quality indicators, or the answer you are hoping for. Queries may be open-ended, multiple-choice, or yes/no (POA). A multiple-choice query must offer only clinically supported options plus an 'other' choice, and there is no mandatory minimum or maximum number of answer options.
How does documentation affect the MS-DRG and reimbursement?
Each ICD-10-CM diagnosis is classified by CMS as a major complication or comorbidity (MCC), a complication or comorbidity (CC), or neither (NonCC), based on how much that condition, as a secondary diagnosis, increases hospital resource use. MS-DRGs are grouped within Major Diagnostic Categories and defined by the principal diagnosis, specific secondary diagnoses, procedures, sex, and discharge status -- so capturing a documented CC or MCC can move a case to a higher-weighted DRG. For FY 2025 there are 773 MS-DRGs. A concrete example of how specificity drives payment: for FY 2025 CMS reclassified seven ICD-10-CM codes describing inadequate housing and housing instability from NonCC to CC, based on their higher average resource costs. The catch is the CC Exclusion List -- some CC/MCC secondary diagnoses do not raise severity when they are closely related to the principal diagnosis, which is why capture has to be validated, not assumed.
What is the Present on Admission (POA) indicator and why does CDI review it?
POA identifies whether a condition was present when the order for inpatient admission occurred; conditions that develop during an outpatient encounter -- the emergency department, observation, or outpatient surgery -- are considered present on admission (per CMS). The Deficit Reduction Act of 2005 requires IPPS hospitals to report a POA indicator on the principal and every secondary diagnosis for discharges on or after October 1, 2007. There are five values: Y (present at admission), N (not present), U (documentation insufficient to determine), W (clinically undetermined), and 1 (exempt/unreported). POA is not paperwork -- since FY 2009, a Hospital-Acquired Condition reported as POA=N is disregarded from acting as a CC or MCC and will not raise the MS-DRG payment, while the same condition reported POA=Y still can. The '1' exempt indicator must never be applied to a code on the HAC list.
Does CDI apply to outpatient and Medicare Advantage, not just inpatient?
Yes. ICD-10-CM diagnosis codes are reported on all inpatient and outpatient claims, and ICD-10 has applied to every HIPAA-covered entity since the October 1, 2015 transition -- CDI is not limited to the DRG. In the outpatient and Medicare Advantage setting, the target is the CMS-HCC risk-adjustment model, where documented chronic conditions map to Hierarchical Condition Categories that drive the patient's RAF score. The 2024 CMS-HCC model is built entirely on ICD-10 (it replaced the ICD-9-based structure) and, per CMS's 2026 Advance Notice, is phased in to 100% of Part C risk-score weighting in CY 2026. Outpatient CDI reviews clinic documentation so those conditions are captured to the specificity the model requires, rather than lost.
How do you keep queries from being 'leading' and creating audit risk?
A leading query -- one that steers the provider toward a particular answer, or that discloses the reimbursement or quality impact -- is a compliance liability, not a revenue win. We hold every query to the AHIMA-ACDIS non-leading standard before it reaches a provider: the statement is neutral, the clinical indicators come from the record, and the answer options are clinically valid. For POA and yes/no queries we include the required 'unable to determine' option, and we treat 'unable to determine,' 'possible,' and 'unable to rule out' as the distinct terms AHIMA-ACDIS says they are -- not interchangeable. There is no required number of clinical indicators a query must carry, because what is relevant varies by diagnosis, patient, and clinical scenario, and the provider makes the final clinical determination as to what defines a diagnosis.
What are the 7 C's of clinical documentation?
There is no single authority that codifies one official '7 C's,' but the version most widely cited across CDI training lists them as Complete, Concise, Correct, Clear, Compliant, Consistent, and Codable -- as published by CDI firm JBH Solutions. Each names a trait a strong record needs: complete captures every reportable condition; correct and clear keep the note accurate and unambiguous; compliant and consistent keep it defensible and internally agreeing; and codable means the documentation is specific enough for a coder to assign the ICD-10-CM code without a query. The seventh C, codable, is precisely what CDI protects -- the bridge between the clinician's note and the claim.
Do you have to be a nurse to do CDI, or what background is required?
No -- you do not have to be a nurse to work in CDI. The field draws from two backgrounds: clinical staff (most often registered nurses, but also physicians) and health information management professionals such as coders. The ACDIS Certified Clinical Documentation Specialist (CCDS) credential reflects both paths -- it accepts an RN, RHIA, RHIT, MD, or DO with two years of CDI experience, or an allied-health associate's degree with three years plus coursework in anatomy, physiology, and medical terminology, or the AHIMA CCS/CCS-P coding credential with three years. Per AAPC, outpatient and HCC-focused CDI leans further toward coding-credentialed staff. Every path shares one skill: reading a clinical record and knowing what the documentation must support.
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See What Your Documentation Is Leaving Uncaptured
Send us a sample of finalized inpatient charts and their MS-DRG assignments. We will show you where the documentation supports a CC or MCC that was never captured, where POA indicators are misreported, and which chronic conditions your outpatient notes are dropping before they ever reach an HCC.
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