CDI Reimbursement Volume 2

Worthy Endeavors Inc provides multiple services but at its core is clinical documentation integrity.

What is “clinical documentation integrity”?

Clinical documentation integrity is ensuring that documentation translates across all perspectives and disciplines to accurately reflect the experience of the patient.

What do we mean when we say, all perspectives and disciplines?

There are 5 perspectives/disciplines:

  1. Reimbursement
  2. Quality
  3. Medical Necessity
  4. Risk Adjustment
  5. Coordination of services

There is a lot of information and documentation to keep track of which is why specific departments within an organization specialize in each of these disciplines and perspectives. Each department has staff who review medical records then apply the rules of their discipline to the documentation.

When the best documentation is achieved, reimbursement is appropriate, quality reporting is accurate, level of care assignment is accurate, risk adjustment scores are accurate, and post-acute care services are medically necessary and appropriate.

To ensure the best documentation is achieved Clinical Documentation Integrity is housed in many different locations within an organization. The most typical areas are Health Information Management (HIM), Revenue Cycle, Quality, or Case Management. How the healthcare system is organized will determine the focus and priorities of a Clinical Documentation Integrity department.

The guiding principle of every clinical documentation specialist should be to seek the “clinical truth”.



A historical perspective

The reimbursement story is best told from a historical perspective. Understanding the history and evolution of CDI is the best way to appreciate what CDI is, where it started, where it is and where it is headed.

Sometime after the beginning…

Somewhere along the way, someone said, “Hey, not all your patients are Medicare… what about those other ones?”. They were right, there are a lot of Medicaid (MediCal for my California friends) patients as well.

There is a different reimbursement model, the All Patients Refined DRG (APR-DRG). For legal reasons, it is “3M™ All Patient Refined Diagnosis Related Groups (3M APR-DRG)” [link below for reference].

The basics of the 3M APR-DRG system are as follows:

  1. The principal diagnosis is selected, the principal procedure is selected, and these two items (with other demographic information) determine the 3M APR-DRG group.
  2. Then you have the Severity of Illness score (SOI) which ranks from one to four.
  3. The relative weights (RW) are assigned lowest (1) to highest (4). The ranking is not based on a single CC or MCC diagnosis like the MS-DRG system, it considers all the diagnoses, as they each have their own individual score. Reimbursement can be determined by multiplying the RW and the hospital rate.

*[Since Medicaid (or MediCal) is administered by the individual States, rates will vary depending on how they are determined. Depending on the actual contracting, reimbursement could be based on a “Per Diem” rate, which is a flat daily rate that can be multiplied by the “Average Length of Stay” (ALOS) or “Geometric Length of Stay” (GLOS or GMLOS).]

What do we query for now?

It is not as straightforward as the MS-DRG system was with the CC/MCC capture approach. From a reimbursement perspective, if one diagnosis is the difference between one severity of illness level and the next, then there is a financial impact based on the presence or lack of that diagnosis.

Can that diagnosis be an MCC? Yes

Can that diagnosis be a CC? Yes

Can that diagnosis not be a CC or MCC? Yes

If you are thinking, that means every diagnosis could potentially be impactful, you are not that far off. The only way to ever know for absolute certainty is to plug in all the diagnoses along with the needed demographic information into the correct grouper version (correct year, National Grouper vs. State Specific) and compare the with the diagnosis to the without the diagnosis. If there is a change, then, yes, that diagnosis was the one diagnosis that pushed the severity of illness rating to the next level. You will find some resources that offer some general guidance on how many diagnoses are needed to get to the next level of with a certain severity of illness scoring, but because the algorithm used is highly complex and utilized unique demographic information you can never say with absolute certainty that this condition is going to raise my severity of illness level on this patient for this encounter.

This reimbursement model helps support the notion that you should always seek the “clinical truth” by having a thorough medical record that lists all active diagnoses to the highest level of specificity to accurately reflect the complexity of the patient being taken care of.



ALOS – Average Length of Stay

APR-DRG – All Patients Refined DRG [Legally 3MTM APR-DRG]

CCs – Complication or Comorbidity

CDI – Clinical Documentation Integrity

CMS – Centers for Medicare and Medicaid Services

DRGs – Diagnosis Related Groups

GLOS/GMLOS – Geometric Length of Stay

HIM – Health Information Management

MCCs – Major Complication or Major Comorbidity

MS-DRG – Medical Severity DRG

ROM – Risk of Mortality

RW – Relative Weight

SOI – Severity of Illness


You might also enjoy