The document lists potential key performance indicators (KPIs) for clinical documentation integrity (CDI) programs. The KPIs include metrics such as the number and dollar amount of claims with query post-coding, medical necessity and clinical validation denial rates measured monthly, claims appeal overturn rates, adjusted net patient revenue amounts, and reporting on denials broken out by individual physicians. The KPIs are intended to enhance the validity, reliability and relevance of a CDI program.

1.
Potential
KPIs
for
CDI
Enhanced
Validity,
Reliability
and
Relevance
• #
and
dollar
amount
of
claims
with
query
post
coding
• #
and
dollar
amount
of
claims
with
query
post-­‐coding/#
and
dollar
amount
claims
DNFB
• #
and
dollar
amount
medical
necessity
denials
measured
per
month
(gross
and
net
patient
revenue)
• #
and
dollar
amount
clinical
validation
denials
measured
per
month
(gross
and
net
patient
revenue)
• #
and
dollar
amount
of
DRG
downcodes
measured
per
month
(gross
and
net
patient
revenue)
• medical
necessity
claims
denial
rate
measured
per
month
• clinical
validation
claims
denial
rate
measured
per
month
• #
and
dollar
amount
of
DRG
downcodes
measured
per
month
• Claims
appeal
overturn
rate
measured
per
month
o Also
measured
by
medical
necessity,
clinical
validation
and
DRG
downcode
claims
appeal
overturn
individually
• Net
monthly
case-­‐mix
trends
(Case-­‐mix
achieved-­‐minus
medical
necessity
denial
case-­‐mix)
• Adjusted
net
patient
revenue-­‐
o Monthly
net
patient
revenue
–medical
necessity,
clinical
validation
and
DRG
downcode
denial
net
patient
revenue

2. • #
and
dollar
amount
of
medical
necessity/clinical
validation
denials
per
month
broken
out
by
individual
physician
(gross
and
net
patient
revenue)
provided
as
a
report
card
• Number
and
dollar
amount
of
higher
weighted
DRGs
billed
to
Medicare
every
month