The CDI lexicon provides a shared language that ensures clinical findings, treatment decisions, and patient acuity are clearly documented with precision.

The use of consistent terminology in regard to CDI not only minimizes ambiguity but also supports accurate coding for alignment of documentation, clinical validation, and regulatory requirements. The organizations can maintain stronger and more reliable records.

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Introduction

Clinical Documentation Improvement (CDI) is crucial for ensuring that the medical record accurately captures a patient’s actual clinical picture.

Clear and consistent documentation strengthens coding accuracy, supports clinical validation, and maintains compliance with CMS and payer requirements. However, CDI terminology is not always used uniformly, resulting in variations in documentation quality. 

This dictionary brings together the core CDI terms that help clinicians, coders, and reviewers maintain a shared understanding and improve accuracy throughout the medical record.

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CDI Dictionary: Key Terms Every Healthcare Team Should Understand

Below is a concise reference guide to the CDI terms that underpin accurate documentation, clinical clarity, and compliant medical coding.

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1. Clinical Documentation Improvement (CDI)

A structured approach aimed at clearly reflecting patient acuity and clinical intent in the documentation. CDI strengthens coding accuracy, supports risk adjustment, and maintains compliance with documentation standards. 

Example: A CDI specialist reviews “renal insufficiency” and seeks clarification to determine whether indicators support acute kidney injury.

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2. Provider Query

A structured communication used to clarify incomplete, ambiguous, or clinically inconsistent documentation so the medical record accurately reflects patient acuity and clinical intent.

Example: CDI issues a query asking whether pneumonia is aspiration-related, bacterial, or linked to sepsis based on available indicators.

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3. MEAT Criteria

A documentation standard—Monitor, Evaluate, Assess, Treat—that confirms a diagnosis is active and clinically supported for coding and risk adjustment.

Example: For Chronic obstructive pulmonary disease - SpO₂ monitoring (Monitor), chest X-ray review (Evaluate), wheezing assessment (Assess), and increased bronchodilator frequency (Treat).

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4. DRG (Diagnosis-Related Group)

A reimbursement framework that ranks inpatient encounters by diagnosis and complexity. Proper DRG assignment depends on clinically supported, specific documentation, which is why precise terminology and validation are essential.

Example: Acute hypoxic respiratory failure, confirmed by ABG findings, increases DRG weight for a pneumonia case.

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5. MCC (Major Complication or Comorbidity)

MCCs are impactful secondary diagnoses that denote serious clinical severity or organ impairment, resulting in an elevated DRG weight.

Example: A patient with pneumonia requiring mechanical ventilation for acute respiratory failure qualifies for an MCC.

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6. CC (Complication or Comorbidity)

CCs represent moderate-severity conditions that increase resource use and influence DRG weighting below the MCC threshold.

Example: When pneumonia is accompanied by dehydration, the additional diagnosis is treated as a CC.

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7. HCC (Hierarchical Condition Categories)

HCCs categorize chronic conditions into weighted groups for risk adjustment; clear documentation determines accurate capture.

Example: Diabetes with chronic neuropathy assigns a higher HCC than diabetes without complications.

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8. RAF (Risk Adjustment Factor)

A numeric value representing a patient’s documented disease burden; MEAT-supported diagnoses determine RAF accuracy for Medicare Advantage and other risk-adjusted programs.

Example: A patient with CHF and CKD stage 4 receives an accurate RAF value only when both conditions are documented clearly with annual recapture.

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9. RADV (Risk Adjustment Data Validation)

A CMS audit process that validates HCC submissions by verifying that each risk-adjusted diagnosis is clearly supported in the medical record with MEAT criteria documentation.

Example: During a RADV audit, CMS reviews charts to confirm that chronic kidney disease was actively managed with lab monitoring (Monitor), GFR assessment (Evaluate), stage documentation (Assess), and dietary counseling (Treat).
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10. CMI (Case Mix Index)

A weighted average reflecting the complexity and resource intensity of an inpatient population. CMI is calculated using DRG relative weights and directly impacts reimbursement. Higher CMI indicates more complex patients requiring greater resources.

Example: A hospital's CMI increases from 1.4 to 1.6 when documentation improvements capture MCC conditions like acute respiratory failure, accurately reflecting patient complexity.
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11. Clinical Indicators

Objective findings from labs, imaging, physical exams, vital signs, and treatments that substantiate a diagnosis. Clinical indicators serve as the foundation for clinical validation and support provider queries.

Example: Elevated troponin levels, ST-segment changes on EKG, and chest pain documentation together provide clinical indicators supporting acute myocardial infarction.
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12. Principal Diagnosis

The condition determined to be chiefly responsible for the admission after evaluation. It drives DRG selection and inpatient reimbursement.

Example: A patient admitted for shortness of breath is diagnosed with acute CHF exacerbation, making it the principal diagnosis.

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13. Principal Procedure (Inpatient)

The procedure performed for definitive treatment of the principal diagnosis or to address the condition chiefly responsible for admission. Principal procedure selection impacts DRG assignment in procedure-driven cases.

Example: For a patient admitted with coronary artery disease, coronary artery bypass graft becomes the principal procedure, driving DRG classification and reimbursement.

14. Secondary Diagnosis

Coexisting or newly developed conditions documented during care, and requiring evaluation, treatment, or monitoring. Only some qualify as CC/MCC status under DRG rules.

Example: CKD paired with pneumonia may change DRG severity, while hypertension may not.

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15. Clinical Validation

A review to confirm diagnoses are supported by objective clinical indicators to prevent unsupported coding and audit denials.

Example: Acute kidney injury documentation is validated through lab trends and urine output changes.

Accurate use of CDI terminology provides a clear foundation for documenting patient acuity and achieving coding precision. Uniform terminology minimizes interpretation gaps and strengthens compliance. 

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HOM combines AI-assisted tools with expert clinical specialists to advance this consistency through structured documentation assessments, validated coding practices, and focused clinical reviews. Our human-in-the-loop approach ensures technology enhances—rather than replaces—clinical expertise.

To discuss how HOM can help strengthen your CDI operations, contact us at partnerships@homrcm.com.

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FAQs

1. How does standardized CDI terminology improve documentation?

It creates a shared understanding across teams, strengthening clarity, coding precision, and alignment with regulatory expectations.

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2. Who uses CDI terms in daily workflows?
CDI specialists, coders, physicians, case managers, and quality teams use these terms when interpreting documentation and supporting accurate code assignment.

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3. Are CDI terms relevant outside inpatient settings?

Yes. Terms like MEAT, HCC, and clinical validation are central to outpatient and Medicare Advantage documentation.

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4. How often should CDI terminology be reviewed?

Regularly—especially when CMS, ICD-10, or HCC updates occur to maintain consistency and compliance.

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5. Why is CDI terminology important for reimbursement accuracy?

Because precise terminology enables accurate coding, which directly affects DRG payment and risk-adjusted reimbursement.

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