Common internal metrics for Clinical Documentation Integrity

Clinical documentation integrity (CDI) departments focus on the integrity of the clinical documentation within a health record. There are many CDI initiatives that healthcare organisations can institute depending on their unique needs. Key performance indicators (KPI) are metrics that can be analysed by organisations to monitor the progress of CDI initiatives. This information can be used to identify strategic goals, operational opportunities, support informed decision-making, and develop focused educational training.  

When monitoring CDI operations, it is important to consider leading and lagging indicators. Typically, leading indicators recognise what a CDI department is working toward (predict future success) and lagging indicators identify what has been achieved by the department (reflect past success). 

To get a complete picture of their performance, CDI departments may monitor KPIs that are internal and external to the organisation. External resources will vary by location and may include patient severity of illness scores and quality measures, while internal metrics can vary depending on the mission and focus of the CDI department. 

Internal metrics may also change as the department matures and the documentation focus areas expand. These metrics should be evaluated on an ongoing basis to continually monitor a programme’s success.  

Some of the common internal metrics that are monitored for CDI departments include the following:  

- Health record review rate: A calculation of the number of health records reviewed by a CDI professional divided by the number of health records assigned for review within a defined period of time. This metric can help identify if the goal for the review rate is realistic.  
 
For example, if none of the CDI staff are meeting the goal, then it may need to be reconsidered. This information can help leadership recognise when additional staff may be needed. It is important for leaders to consider all the variables that can influence the review rate such as time spent delivering provider education, department meetings, competing responsibilities, and patient acuity.  
 

- Provider response rate: The percentage of provider responses to queries within a defined time frame. This is one of the most important metrics; if providers are not responding to queries in a timely manner, errors and omissions in the documentation can impact reimbursement, quality care, and patient outcomes. This may be monitored by CDI professional, individual providers, provider groups, or by the CDI department.  
 

- Query rate: The percentage of queries being sent to providers compared to the number of health records reviewed by the CDI professionals. This metric may be measured by the actual number of queries sent or by the number of health records requiring one or more queries. This metric can assist the organisation in determining the quality of the clinical documentation, engagement of providers, and educational opportunities.  
 
The query rate may decrease as the providers improve their clinical documentation. It can also increase again if new documentation needs occur. For example, if the CDI team begins by only sending queries that capture disease severity, then as the providers improve in this area the query rate will drop. Then if the CDI department begins reviewing documentation that impacts quality metrics the query rate may increase.  
 

- Provider agreement rate: Measurement of the number of times the provider agrees with the need for further documentation clarity, based on the queries they receive. This metric helps monitor the engagement of providers and the quality of the queries being sent. For example, if the provider has a low agreement rate, they may not be engaged with the program or they may be receiving inappropriate queries. 
  

- Denial rate: The percentage of claims that have been denied by payers within a defined time frame. This information can be further evaluated by the type of denial such as missing or incomplete documentation, inaccurate coding, and not meeting medical necessity for services provided. 

Organisations will need to determine which metrics they will monitor and develop a process for data collection and analysis. The process of data collection is vital to the accurate measurement of KPIs for the CDI department. The information may be collected through an internal, manual process, like adding the information into an Excel document. It may also be collected through automated CDI technology.  
 
If there are budgetary restraints, the information may need to be collected manually; however, this does increase the chance of error and may consume large amounts of staff time. Obtaining CDI software can help support the accuracy of data collection and free up staff time to perform more health record reviews. There are many opportunities to advance CDI efforts through the use of technology.  
 
To learn more about CDI Technology you can review the publication, Compliant CDI Technology Standards. There are also many educational opportunities available regarding the use of CDI technology, such as The Impact of Technology on Clinical Documentation Integrity Webinar Series.  

There are both quantitative and qualitative data collection methods and the type used will be dependent on the information being measured. Quantitative data is obtained through mathematical calculations and is frequently monitored by a CDI department, while qualitative data uses open-ended questions to collect data. This method might be used when interviewing providers or staff regarding their specific needs.  
 
This can also be used by manually performing quality audits on health records that have been reviewed for missed opportunity and auditing for query compliance. These quality audits are essential to the performance of the programme, some organisations may want to use external sources for auditing, such as the CDI Query Services offered by AHIMA CDI Experts. 

Providers are essential in CDI initiatives to improve documentation and patient outcomes, and need clear and concise documentation guidance that supports rather than distract from patient care. CDI departments may utilise unique and creative approaches to address documentation needs that support care across the continuum. CDI metrics can also be used to help educate providers on the importance of data integrity, which in turn supports provider engagement.  

To learn more about CDI KPIs, please review the Clinical Documentation Integrity Key Performance Indicators Practice Brief (ahima.org) 

AHIMA supports the ongoing needs of CDI professionals and physicians through an extensive suite of CDI education and publications. Visit the AHIMA CDI Progression Ladder website to find educational opportunities that supports all stages of a CDI professional’s career.