How Do CDI Programs Impact the Patient?

This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.


We talk a lot about the impact of clinical documentation improvement (CDI) on healthcare organizations and physicians. We look at ways to reflect appropriate reimbursement and accurate quality scores, both of which are very important. But do we take the time to look at the true extent of the impact CDI has on our patients? Patients look at quality scores to choose providers and organizations. Patients deserve accurate information to make a well informed choice on where to receive care. However, sometimes we forget about the other ways CDI may impact patients. Let’s take a look at an example of the impact that CDI may have on a patient as they move beyond the acute care setting to better visualize this concept.

Example Scenario:

This is a 48 y/o male that has hypertensive end-stage renal disease (ESRD) and is on home peritoneal dialysis. He recently had knee replacement surgery. Two days after being discharged home, he went into respiratory failure and was rushed back to the hospital. It was determined he was in fluid overload secondary to a blockage in the peritoneal dialysis catheter from fibrin. This was treated with heparin and returned to normal function. He was discharged home with home health nursing and physical therapy.

After being discharged home, the wife and home health nurse noticed the patient’s oxygen level would continue to drop to the low 80’s to upper 70’s every time he fell asleep. The primary care physician was called and home oxygen was ordered for a decrease in oxygen saturations. A sleep study was also scheduled. The patient then received a call from the home oxygen vendor and was told his insurance would not cover home oxygen for his condition. He was told the only way it could be delivered was if he paid for it out-of-pocket. It is now 5:00 pm on a Friday evening and the doctor’s office is closed.

This would be of great concern to a patient in this situation. He knows he needs the oxygen but does he have the money to pay for it? The patient is sick enough to need the oxygen but unfortunately the clinical documentation doesn’t have the specificity needed to reflect the true condition of the patient. Home oxygen has a specific set of requirements under the National Coverage Determinations (NCDs) for Medicare that must be met before the treatment will be approved. Some other payers also use these criteria to support medical necessity of certain treatments.

It is important for providers to be aware of National Coverage Determinations and Local Coverage Determinations (LCDs). The Centers for Medicare and Medicaid Services has a website where providers can go in and look at the NCD and LCD requirements (https://www.cms.gov/medicare-coverage-database/indexes/national-and-local-indexes.aspx).  In the hospital, patients have case managers who ensure these requirements are met before discharge. But  this is not the case in many outpatient settings.

Have you ever heard of or been in a situation such as the scenario above? What would you suggest for the patient to do? Go back to the hospital for readmission? Just sleep without the oxygen and hope for the best?

Tammy Combs, RN, MSN, CDIP, CCS, CCDS, is director and lead nurse planner of HIM Practice Excellence for AHIMA. She provides professional practice expertise to AHIMA members, the media, and outside organizations on clinical documentation improvement (CDI) practice issues. Combs authors material and provides support for AHIMA’s online CDI education platforms. She also serves as faculty for the AHIMA CDI Academies and CDIP Exam Preps, and is a technical advisor for AHIMA on CDI publications.

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