What is the best action to validate that a clinical documentation improvement (CDI) program is achieving its goals?

Conducting a retrospective review of all query opportunities for the year is the best action to validate that a clinical documentation improvement (CDI) program is achieving its goals. This approach allows organizations to analyze the effectiveness of their CDI initiatives by examining the queries raised throughout the year. By reviewing these queries, the organization can assess whether the documentation is improving, if the queries are being resolved satisfactorily, and if the physicians are responding appropriately. It provides tangible evidence of how much the CDI efforts have influenced documentation quality and coding accuracy, ensuring that the program is aligned with its objectives.

On the other hand, hiring clinical documentation specialists to review records prior to coding focuses more on immediate quality checks rather than long-term program effectiveness. Asking coders to query physicians more often might increase the volume of inquiries but does not necessarily reflect improvements in documentation quality. Providing physicians with the opportunity to add addenda to their reports can enhance accuracy, but it does not evaluate the overall impact of the CDI program. Therefore, the retrospective review is the most comprehensive method to validate the success of a CDI program.