CDI Support

Clinical Documentation Integrity (CDI) Education and Query Review Services

With complete and accurate clinical documentation driving quality metrics, accurate reimbursement, and performance-based contracting, getting physicians to improve their documentation is a critical priority. Our peer physicians work directly with your providers, identifying cases and trends where there is opportunity to improve documentation effectiveness and drive immediate revenue results.

Get credit for the high-quality care you provide

Effective clinical documentation is critical to accurately capture the high quality of care that your hospital provides. When documentation opportunity exists, an organization’s fiscal health as well as public perception can be jeopardized due to innappropriate reporting of patient safety events and complications.

Our clinical physician advisors can help


Capture and clarify diagnoses that impact quality metrics


Review and clarify present on admission (POA) status


Ensure accurate reporting of Severity of Illness (SOI) and Risk of Mortality (ROM)


Ensure risk-adjustment methodologies are optimized

Compliant Documentation Education

Our physician advisors educate hospital physicians on proper and effective documentation to support optimization of the DRG and quality metrics.

Use physicians’ own documentation

To provide direct education to capture medical necessity as well as severity of illness (SOI) and risk of mortality (ROM) of their patients.

Provide education

That is focused on demonstrating quality to improve physician buy-in.

Provide customized tips

For documentation education that include reference links to evidence-based literature for providers’ ongoing reference.

Query Support

We help hospital clients tackle the ongoing challenges surrounding queries, including unable-to-determine and unanswered queries. When clients seek our support for specific query concerns, we provide physician-to-physician documentation feedback to reduce future queries.

Mortality Risk Adjustment Optimization

Documentation and coding of all reportable ICD-10 diagnoses is critically important to ensure accurate portrayal of risk. In addition, many quality metrics only utilize diagnoses captured as Present On Admission (POA) for risk adjustment. These risk models are often very complex and require an appreciation of the methodology to effectively optimize Observed to Expected (O/E) ratios.

Our team has deep knowledge of multiple risk models and can work with your organization to guide your team and teach your providers.

Case Reviews

We assist hospital organizations to improve key performance indicators (KPIs) through our focused review services, based on the following factors:


gaps identified through data analytics


identified through internal metrics


of new clinical practice guidelines


by specialty, provider groups, individual providers, diagnosis, procedure or other subset needing concentration

Our Results Include

Increased case mix index through capturing comorbidities that were treated or monitored but not captured through accurate or complete documentation

Improved quality metrics by validating the presence or absence of accurate and complete documentation of comorbid conditions and complications

Accurate reimbursement through precise reporting and billing of comorbid (secondary) conditions that affect patient care in terms of requiring:

    • Clinical Evaluation
    • Therapeutic Treatment
    • Diagnostic Procedures
    • Extended Length of Hospital Stay
    • Increased Nursing Care and/or Monitoring

    The Purpose of CDI

    It ensures that the clinical documentation accurately reflects the complexity and severity of patients’ conditions, enabling healthcare providers to receive appropriate reimbursement for the care provided.

    It supports the reporting of quality metrics, aiding in the evaluation and improvement of healthcare outcomes.

    It promotes compliance with regulatory guidelines and standards, mitigating potential risks and liabilities for healthcare providers.

    Impact and Benefits

    Implementing a robust CDI program can have a profound impact on hospitals and their stakeholders. By enhancing the accuracy and completeness of clinical documentation, hospitals can experience several benefits:

    Compliantly Capture Earned Revenue

    Accurate and comprehensive documentation ensures appropriate reimbursement for the services provided, reflecting patient cases’ true acuity and complexity. This leads to optimized revenue capture, supported hospital margins and increased financial stability for hospitals.

    Improved Patient Care

    Clear and precise clinical documentation facilitates effective communication among healthcare providers, resulting in better coordination and continuity of care. It enables accurate clinical decision-making, reduces medical errors, and enhances patient safety and outcomes.

    Enhanced Compliance

    Proper clinical documentation ensures compliance with regulatory requirements, coding guidelines, and documentation standards. This reduces the risk of audits, penalties, and denials, safeguarding hospitals’ reputations and financial standing.

    Quality Metrics and Performance

    Accurate documentation allows hospitals to measure and report quality metrics, supporting performance improvement initiatives. It enables benchmarking against industry standards and facilitates data-driven decision-making to enhance overall healthcare delivery.

    Process of Improving Clinical Documentation

    The process of improving clinical documentation involves a comprehensive approach that integrates education, technology, and ongoing evaluation. Brundage Group offers tailored solutions to support hospitals in this journey.

    Specialist Education

    Our expert physician advisors provide comprehensive education and training to clinical documentation specialists, ensuring the knowledge and skills to support hospital providers in accurately capturing and documenting patients’ diagnoses, procedures, and treatment plans.

    Physician Education

    We work directly with physicians, conducting targeted education sessions to enhance their understanding of proper documentation practices. By bridging the gap between clinical expertise and documentation requirements, we empower physicians to effectively communicate the complexity and severity of patient cases.

    Technology Integration

    Brundage Group leverages advanced, proprietary technology solutions to help track the effectiveness of clinical documentation practices. We provide hospitals with tracking tools and systems to monitor clinical data capture trends, with analysis and reporting to support the CDI program’s effectiveness.

    Ongoing Evaluation and Feedback

    Continuous evaluation and feedback are vital to sustaining improvements in clinical documentation. Our physician advisors collaborate closely with healthcare and hospital providers, conducting audits, providing constructive feedback, and identifying areas for further enhancement.

    Frequently Asked Questions

    What is the role of clinical documentation in capturing revenue for hospitals?

    At Brundage Group, we understand the importance of accurate clinical documentation in optimizing hospital revenue. Through our CDI solutions and education programs, we help healthcare providers capture the complexity and severity of patient cases, ensuring appropriate reimbursement and compliantly capturing earned revenue to remain viable.

    How can clinical documentation improvement impact patient care outcomes?

    Improving clinical documentation directly enhances patient care outcomes. With precise and comprehensive documentation, healthcare providers can access the necessary information to make informed clinical decisions, reduce errors, and improve patient safety. Our CDI programs empower physicians and clinical documentation specialists to enhance the quality of care delivered to patients.

    How does Brundage Group ensure compliance with regulatory guidelines and standards in clinical documentation?

    Compliance with regulatory guidelines and standards is crucial in clinical documentation. At Brundage Group, we stay updated with the latest regulations and provide tailored education and training to ensure healthcare providers are aware of documentation requirements. By promoting compliance, we help hospitals mitigate denials, maintain positive public perception, and navigate complex regulatory landscapes.

    What benefits can hospitals expect from implementing a CDI program?

    Implementing a CDI program yields several benefits for hospitals. Our services focus on maximizing revenue through accurate reimbursement, improving patient care quality and outcomes, enhancing compliance, and supporting quality metrics reporting. By partnering with us, hospitals can experience financial stability, improved patient outcomes, and enhanced overall performance.

    How does Brundage Group support ongoing improvement in clinical documentation integrity?

    Brundage Group believes in the power of continuous improvement in clinical documentation integrity. We provide ongoing support through our physician advisors, who conduct audits, offer feedback, and identify areas for further enhancement. By combining education, technology integration, and ongoing evaluation, we help hospitals foster a culture of continuous improvement, ensuring the highest standards of clinical documentation integrity.

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