Clinical Documentation Improvement Program

Clinical documentation improvement programs are an important piece of the preparation for ICD-10 implementation.  Documentation details why a person seeks care, what care was provided and may be used as defense in malpractice claims and to support the medical necessity of care. 

Each physician’s records must support both the diagnosis and the procedures performed at every visit.  In order to receive reimbursement from a third-party, documentation must be clear and concise.  Vague documentation may results in questions, error and claim denials.

In the current healthcare environment, CPT coding drives reimbursement and many review are focused on whether the procedure codes are supported within the documentation.  With the introduction of ICD-10, there is an increased emphasis placed on diagnoses becoming an important factor in reimbursement decisions. 


Chiropractic reviews frequently cite “insufficient documentation” as a basis for denial.  Focusing on documentation improvement prior to the implementation of ICD-10 will help to reduce denials or assignment of
unspecified codes.  Although there are times when the use of these less-specific codes is appropriate, routine use will result in decreasing reimbursements.  Physicians must take the time to document the specifics to ensure accurate code selection.

A patient’s treatment plan is dictated by the diagnosed condition.  Failure to properly document and assign ICD-10 codes brings increased risk in reimbursement, not only are the initial CPT codes called into question, but the patient’s entire treatment plan may be denied.   

There are several challenges to a clinical documentation improvement program. 

  • Improving documentation without creating excessing administrative burdens and, physician frustration.
  • Identifying the correct details needed, not creating a volume of detail for each visit.
  • Preparing the documentation without encroaching on time spent on patient care.

Physicians have the unique challenge to try and fit the new coding and reimbursement system into their daily clinical workflow without adversely impacting patient care.  Beginning well in advance of ICD-10 is advised.

There are 4 steps to a Clinical Documentation Improvement (CDI) program.

  1.  Assess.  Evaluate the current status of medical records.  Does it support the ICD-9 codes used today?  Will it support ICD-10 code selection?  Does the record support the CPT codes billed?  The outcome of the assessment phase indicates areas of potential improvement for both diagnosis and procedure coding.
  2. Education.  Physician education, training and tools are vital to a successful CDI program.  Training via classroom, webinar, video, or articles can be used to support providers. 
  3. Implementation.  In this step providers and staff work together to support the creation of EHR templates, worksheets and reference tools to make the changes identified in the assessment step.
  4. Maintain.  A CDI program must be maintainable to provide value.  The changes made as a result of the previous steps should be monitored and assessed regularly to ensure that documentation continues to reflect the requirements of the payers as well as federal and state regulations.

The focus of a CDI program should be on increasing the accuracy and completeness of documentation regardless of the impact to the bottom line.  Don’t focus only on the highest dollar services, but on all procedures performed in the clinic.  The most vital role of the CDI program is completely and accurately reporting both diagnosis and procedure codes.

Cornerstone offers Documentation Readiness Assessments and Chart Audits to help you in your CDI program.  The Chart Audit looks at ICD and CPT coding.   Does the information in the chart support the ICD-9 code and have the elements needed to support the CPT codes billed?  The Documentation Readiness Assessment looks specifically at documentation supporting ICD-10 coding.  Based on your documentation today, what ICD-10 code could be assigned and what details, if added, could improve that code assignment. 



Are You on Target for ICD-10

Where are you now?

Unlike many other healthcare programs, the ICD-10 program is not tied to any incentive program.  The cost of implementation are hard costs that have a direct impact on the provider’s bottom line. The change from ICD-9 to ICD-10 represents significant effort and risk.  If it is not implemented correctly or completely, the effect on the practice could be significant.

While CPT/HCPCS coding drive provider reimbursement, an incorrect or incomplete diagnosis code will halt reimbursement.  Because ICD-10 impacts every part of your clinic, it requires careful management for successful implementation.  Physicians face a unique challenge of working to fit a new coding and reimbursement system into their daily clinical work-flow while staying focused on patient care.

The increasing level of detail in the ICD-10 coding requires clinical staff to focus on documentation improvement.  Without the correct level of documentation in the medical record it will be impossible to support the new, more specific codes.  This will leave the office with unsupported diagnoses for medical necessity or with using only “unspecified” codes.  While the jury is still out on how payers will treat these codes, they are expected to deny or delay payment.

For example:  ICD-9 Code 722.71 is Cervical disc degeneration with myelopathy.  Under ICD-10 you are required to identify the level of the degeneration: Occipito-atlanto-axial, mid-cervical or cervicothoracic region.  ICD-10 also requires the indication of radiculopathy or myelopathy.  Failure to provide the details needed may require the use of the “unspecified” region or prevent the use of the diagnosis which will impact the medical necessity determination for your claim.

Begin today adding details such as laterality, spinal regions and specific spinal segments to your documentation. 

“An ounce of prevention is worth a pound of cure” Benjamin Franklin

 One of the key steps toward successful implementation is a Clinical Documentation Improvement Program (CDIP).   The goal of a CDIP is to promote clear, concise, complete, accurate and compliant documentation.  This is accomplished through analysis and interpretation of medical records.  The goal is to identify and rectify situations where documentation is insufficient to accurately support the patient’s severity of condition and care.  Suggested improvements may include specificity of principal diagnosis, associated comorbidities or complications.

Due to the increased level of specificity inherent to ICD-10, clinical documentation to support the detailed coding must exist within the medical record.  Incomplete documentation will cripple a provider's ability to appropriately assign and support the ICD-10 codes.  An insufficiency in this area could impact a provider's revenue cycle in several areas: reimbursement delays, increased records requests and denials.  Each error may increase the overall billing cycle time, increase the overall accounts receivable days and may potentially increase denials for medical necessity. 

Many physicians feel their EHR system provides protection and insures proper code selection.  Recent records reviews from many EHR's show that this is not necessarily the case.  EHR software not designed to ensure that the records generated support either CPT or ICD code selection, regardless of sophistication.


The downstream effect of inaccurate or incomplete clinical documentation include:

  • Inaccurate or incomplete ICD-10 code assignment which can impact reimbursement and increase compliance risks.
  • Failure to meet medical necessity requirement can potentially jeopardize reimbursement
  • Inaccurate data used for quality reporting can result in reduced payments
  • Increased days in A/R may result from the inability to submit claims timely, decreased claim acceptance and increased claims denials which negatively impact cash-flow
  • Increased patient dissatisfaction.


Start with a review of where your records are today.  Reviewing current patient examination records and identifying barriers to assigning ICD-10 codes will help in identifying changes to be made.  Then, by providing targeted education to each provider to address known deficiencies, improvements can have the greatest impact. 

Identifying your practice's top diagnoses and targeting your documentation improvements to those codes first will help your office become prepared for the ICD-10 implementation.

Cornerstone offers a clinical documentation readiness assessment.  For details about the program, click here.


The Exam

Documenting Medical Necessity with Your Exam

Audits.  Repayment requests.  Claim denied for Medical Necessity.  Concurrent reviews.  Retrospective reviews. Are you frustrated by insurance companies that do not pay your claims?  Are you spending time and money appealing these situations – and losing the appeals?  Insurance companies are finding ways to deny claims for all physicians by reviewing your notes against the requirements from the CPT manual. Benefits are often determined by record review.

This new environment demands extensive and thorough documentation, while fee schedules and the realities of business mean that doctor’s offices need to be as efficient as possible.  Don’t get discouraged – get the tools to fight the denials!  Learn what documentation techniques work – and which ones to avoid.  It is important to “tell a compelling story” with your documentation. It is the only thing a reviewer has to base his or her review decision on.

Documentation requirements are different for each type of visit:  Initial Examination, Progress Examination(s), Daily Treatment(s) and Final Visit.  Over several articles we will be looking at each type of visit and the documentation requirements of each as defined by the CPT manual, Medicare documentation rules and generally accepted coding guidelines.

Initial Examination

Evaluation and Management Codes (E&M) are used to identify the initial examination.  The visit can be coded as new/established patient visit or consultation.  If you expect to take over the care of this patient do NOT use the consultation codes; the new/established patient codes are the correct E&M.  If you are rendering an opinion and transferring care back to the referring physician then the consultation codes should be used.

To properly document an E&M code you must include history, examination findings, medical decision making and counseling, and, in certain cases, co-ordination of care.  The first three are considered key components of the code.  Let’s break each one down individually.

History must contain a concise statement to describe the problem and what brought the patient to your office (chief complaint). As the physician gathers more data regarding the patient’s condition reviewers are looking for quantifying information in the HPI (history of present illness). Identify the location, quality and/or severity of the problem. It is also necessary to explain the mechanism of injury (if appropriate), duration, timing and context of the issue. Always include what improves or deteriorates the condition as well as any treatment(s) that have been tried at-home and under the care of other physicians. A problem pertinent Review of Systems (ROS) and Past, Family and/or Social History (PFSH) should also be included.


Example: Patient is a 35 year old female who presents today with low back and leg pain. Patient denies any trauma or injury and states she awoke with the pain three weeks ago. The pain radiates into the right hip and she has numbness in the bilateral lower extremities. She describes the pain as constant and rates the pain the pain as an 8 on a scale of 1 to 10. Sitting or standing increases the pain and ice decreases the pain. Patient saw her PCP and was prescribed 5 mg. Flexeril b.i.d. but the condition has not improved.


Any forms filled out by the patient during your examination should be reviewed by the physician and noted on the form. The documentation in this area should describe range of motion, orthopedic and neurologic testing performed as well as palpation and postural abnormalities.   

Medicare Decision Making is the most important piece of information in determining the level of care to bill.  In this section of the documentation, there are three items to be considered:  the number and complexity of medical records, tests and other items to be reviewed; number of possible diagnosis and /or management options to be considered; and the risk of complications. Recording initial clinical impressions should mimic the processes that the doctor goes through in clinical decision making.

The diagnosis you select must be as specific as possible and must be supported by the HPI and an examination that relates the complexity of the presenting problem and diagnostic procedures performed.  Do not list every possible diagnosis in your selection. Select only the most appropriate most specific diagnosis for this patient for the condition(s) you are treating. Do not list diagnosis for conditions you are not treating, unless they change your treatment plan.

 One of the most frequently missing or incomplete elements of chiropractic care is a complete treatment plan.

 This piece is critical in helping the reviewer understand where you are headed with the patient and approximately how long you expect this phase of care to last. Including an estimated total duration of care can also be appropriate. It should describe the level of adjustment, passive or active therapies and the effect those modalities will have in achieving maximum improvement. It should describe the duration and frequency of visits, any home exercises or educational activities you recommend to the patient and your re-evaluation strategy.

The last and most important piece of the plan is establishing goals. Goals should be realistic for the period and should be listed in terms of activities of daily living. They must be objective measures that will evaluate the effectiveness of the treatment. Failure to clearly state your treatment plan – including goals – makes it easier for the reviewer to deny care.


Example:  The patient is in a relief phase of care and is expected to experience symptomatic relief within 2-3 weeks.  During this phase of care the patient will be seen 3 times a week for a period of 3 weeks.  The patient will receive diversified adjustments to the lumbar spine to restore normal joint mobility and aid is dissolution of articular fixations and 12-15 minutes of neuromuscular stimulation to relieve pain, reduce muscle spasm, reduce edema and increase circulation.

 Goals of Treatment in this Phase of Care: Therapy is focused to control injured tissue inflammation, reduce pain, reduce spasm in order to prevent further functional loss and maintain the current level of physiological capacity.  During this phase of care additional goals are that the patient is able to ride in the car for 30-60 minutes without back and leg pain and patient is able to put her shoes on without assistance and marked pain.

Re-evaluation of this patients care plan and goals will be done in 3 weeks.


By thoroughly documenting the initial encounter with the patient the physician provides the reader with a comprehensive “picture” of the patient as they presented in the office.  The reader also has a clear understanding of the activities performed, the clinical justification for the care and the plan of care being utilized at this juncture.

Properly documented evaluation and management codes are difficult to bundle or deny.