Background: Accurate coding is paramount to hospital revenue generation and is often supported by a clinical documentation integrity (CDI) team made up of registered nurses and non-clinical coding personnel. Physician-led coding initiatives have demonstrated improvement in case-mix index and clinical documentation. We hypothesized that physician integration into CDI would result in a more robust improvement […]

Background: There is no formal curriculum for medical students, residents or advanced practitioner students on appropriate clinical documentation improvement (CDI). As the primary documenters for medical records, several studies have shown benefit in billing, coding and hospital metrics with trainee education [1-2]. Despite this, there remains a scarcity of education on documentation for residents and […]