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Abstract
Clinical documentation improvement (CDI) programs have been around since the late 1990s. Facilities who were early adopters of these programs understood the correlation between provider documentation and facility reimbursement. In general, CDI programs were implemented as the result of overall revenue-cycle assessments that identified potential financial opportunity related to diagnosis-related group (DRG)-based payments. One of the basic tenets of compliant coding is that code assignment can only be based on provider documentation -- what is actually written or dictated by the provider; coders are not allowed to make assumptions to assign codes. Thus, the focus of early CDI programs was improving provider documentation for those selected conditions that would optimize or maximize the DRG, thus increasing facility reimbursement. There is obviously no established formula for securing a timely and favorable decision from an ALJ reviewing the denial of Medicare coverage and payment of claims. The overwhelming number of appeals being filed and pending at OMHA inevitably will result in delays.