Top 3 Crucial Distinctions Between Inpatient & Outpatient CDI

Inpatient & Outpatient CDI
Photo by EVG Kowalievska:

An individual's medical record, which is a repository for their health information, is where clinical documentation is recorded. A doctor, dentist, chiropractor, or other healthcare providers may write the entries in the medical record. Regulations, accreditation criteria, corporate policies, and other rules may limit who is allowed to document a medical record in specific instances. 

Both "inpatient" and "outpatient" might relate to the clinical context, but they can imply the treatments being carried out in that setting. Hospitalization is required for most inpatient treatments, usually for patient monitoring and recovery. Instead of an overnight stay in a medical facility, outpatient procedures typically refer to tests and therapeutic treatments that are completed at a medical facility within a few hours and are less expensive.

Here is an analysis of the differences between CDI received in a hospital setting and those received in inpatient and outpatient settings:

There is a unifying goal for both inpatient and outpatient CDI (clinical documentation improvement) to guarantee accurate and thorough documentation that represents the patient's treatment. An individual's CDI goals may include any of the following:

Inpatient - By recording the CC or MCC and quality measures like the severity of sickness (SOI) and mortality risk, the DRG can be accurately and appropriately assigned in the inpatient setting.

Outpatient- Documenting and reporting the relevant hierarchical condition categories to improve the risk adjustment factor (RAF) score in outpatient care.


Inpatient and outpatient CDI programs differ in the following three ways:

Various Payment and Workflow Methods – Patients in the outpatient context face a variety of payment options and workflows. It's common for outpatient settings to run independently, and each office or practice may operate differently, while inpatient facilities are often centralized and so work consistently.

Volume of Patient Encounters – The number of patients seen in a doctor's office is much higher than the number of patients seen in a hospital. Physician office visits totaled 883.7 million in 2018, while hospital admissions totaled 36.3 million, according to CDS Fast Stat. As a result, due to the obvious number, not every chart can be examined and interrogated in an outpatient setting.

Return on Investment (ROI) Calculations – There are various points in the revenue cycle where return on investment (ROI) estimates are made. Because of the impact of the Risk Adjustment Factor (RAF) score, the return on outpatient CDI is not immediate. A positive DRG difference indicates success with outpatient CDI since results are seen at the time of patient discharge.

Starting or expanding CDI to physician offices begins with an understanding of the variations between inpatient and outpatient CDI.


What Is Clinical Documentation Improvement?

It is the process of examining medical records for completeness and correctness, known as CDI. An evaluation of the illness process and diagnostic results is part of the CDI. They may have both clinical and medical coding expertise as a CDI specialist. CDI initiatives are driven by bridging the gap between clinical documentation and correct coding.

Diagnostic and laboratory test results, as well as specialist consultation notes, may be included in patient medical records, but in the context of CDI, "clinical documentation" generally means the entries made by the provider or clinical staff member who is liable for the patient's care during a face-to-face visit.


Purpose of a Clinical Documentation Improvement Program

The goal of a clinical documentation improvement program is to increase the accuracy and completeness of medical records.

What is the purpose of CDI programs? A lot of the administrative work that goes into providing patient care and filing insurance claims has been simplified because of the prevalence of electronic health record (EHR) systems. However, the medical provider will always be responsible for medical record documentation, which is the recording of clinical information about the care that was given to a patient. It is the job of a CDI specialist to verify that the documentation of a patient's current health conditions is accurate so that the patient's health status can be accurately coded.


Effects and Advantages of a CDI Program in an Inpatient Environment

Improvements in CDI's accuracy can lead to more accurate compensation for inpatient institutions. It's not just the first payment of claims that an inpatient CDI program has a financial impact on, though. Poor documentation can lead to inaccurate claim submissions, which can lead to audits that require facilities to pay a fine or restore money that was wrongly collected from payers.

As a result, CDI plays an important role in the claims processing process in healthcare facilities, helping to ensure more accurate initial reimbursement while also helping to avoid costly implications from further evaluations.


Effects and Advantages of a CDI Program in an Outpatient Environment

The financial impact of a CDI program in the outpatient setting can be equally as great as in the inpatient situation. A healthy revenue cycle is essential for provider offices because it allows them to cover their costs and pay their employees, but claim denials or changes as a result of incorrect code submissions can cause delays in receiving payment for services given.

An office or outpatient CDI program's primary goal is to prevent these denials and changes while simultaneously ensuring that documentation is complete for clinical purposes.

Patient outcome-based quality services, including office visits, vaccines, and small procedures in the doctor's office, are becoming more important for both patients and physicians, and CDI plays an increasingly important part in this process.


How CDI Can Help Maximize Revenue

One advantage of inpatient CDI programs is that they prevent claims from being submitted with unsupported diagnoses. However, it is equally vital to ensure that all clinically validated diseases are documented because of the way inpatient facility reimbursement works. For an inpatient institution to be successful with a CDI program, an understanding of Medicare's DRG payment system is a necessity. Adaptations of the DRG payment system are also widely used by non-Medicare providers and payers.

Diagnosis-related groups (DRGs) are exactly what they sound like: groups of linked diagnoses that affect care while a patient is in the ICU. It is determined by the patient's primary diagnosis and up to 24 secondary diagnoses, covering comorbid conditions (CC) and major comorbid conditions (MCC). Reimbursement and reimbursement are linked in the following scenario.



The effectiveness of a CDI program depends on the specialist, regardless of whether the patient is an inpatient or an outpatient. CDI evaluations should only be performed by highly competent personnel. Nursing and CDI-trained medical coders are excellent choices for such roles.

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