Medical Coding & HIM

CDI specialists review medical records concurrently (during the stay) to identify documentation gaps that affect code accuracy, severity capture, and quality reporting. You query physicians when documentation doesn't reflect the clinical picture: a patient clearly being treated for sepsis but documented as 'infection,' a patient with respiratory failure on BiPAP but no documentation of acute respiratory failure, or a patient with malnutrition indicators but no dietary assessment documented. CDI directly impacts DRG assignment (Case Mix Index), risk adjustment (HCC capture), quality measures (PSIs, HACs), and mortality indices (O/E ratios).

You process requests for medical records from patients (Right of Access under HIPAA), attorneys (with valid authorization), other providers (for continuity of care), payers (for claims review), government agencies (subpoenas, law enforcement), and disability/insurance companies. Each request type has different authorization requirements, fee schedules (state-specific), response timelines, and redaction requirements (behavioral health, substance use disorder under 42 CFR Part 2, HIV, reproductive health in some states). Volume is significant: a large health system processes thousands of ROI requests monthly.