What is the goal of a clinical documentation improvement (CDI) compliance review?

The primary goal of a clinical documentation improvement (CDI) compliance review is to generate compliant queries and obtain physician responses. This process is vital in ensuring that clinical documentation accurately reflects the patient’s condition and the services provided. By focusing on generating compliant queries, the CDI process helps to clarify any ambiguities in the documentation, which leads to accurate coding and billing practices. Obtaining responses from physicians is essential as it facilitates the necessary updates to the medical record, ensuring that the documentation is complete, accurate, and compliant with regulatory requirements.

As a result, the correct answer highlights the specific focus on enhancing the quality of clinical documentation through communication with healthcare providers. This is fundamental for achieving compliant and effective documentation that meets the standards set by coding and billing regulations. The process ultimately supports improved patient care and outcomes by ensuring that the healthcare provided is appropriately captured in the medical record.