The importance of physician acceptance for Clinical Documentation Improvement (CDI) efforts has been acknowledged since the inception of CDI programs. This is because the physician, alone, is ultimately the one responsible to establish a patient’s diagnosis. With a plate too full already, and lack of coding knowledge, many physicians have difficulty translating a patient encounter into accurate terminology which can then be coded to the highest degree of specificity possible.

Individual physician buy-in, or engagement into CDI incentives is frequently of mixed degrees. It is of utmost importance that physicians understand clarification efforts are not based on improvements in reimbursement potential alone. With numerous payer models and quality reporting requirements, there is much more at stake for the physician and health system with poor documentation.  Physicians must realize that quality documentation improves patient outcomes, improves physician profiles, reduces claim denials, and improves hospital reporting data along with more accurately increased reimbursements.

AHIMA published a Practice Brief (Journal of AHIMA, July 2017) called, “Impact of Physician Engagement on Clinical Documentation Improvement Programs. This practice brief identifies best practice approaches to obtain physician engagement. While there is not one single approach to obtain physician trust in CDI incentives that works best for each healthcare system, it is acknowledged the significance of having a designated physician champion and medical staff directors onboard for CDI efforts.


By Barb Brant, MPA RN CDIP CCDS CCS