As the curtain closes on ACDIS Inspire 2025, held in Orlando, Florida, it’s an opportune moment to reflect - not only on the impressive scale and maturity of clinical documentation integrity (CDI) in the United States - but also on what these developments mean for Australia and other ICD-10-AM countries as we chart our own course forward in CDI. At the heart of this reflection lies the reality that CDI, while often viewed through a clinical lens, is profoundly shaped by the healthcare systems in which it operates. The U.S. context - marked by a complex payer-provider models, competitive billing dynamics, and a high level of regulatory scrutiny - has driven a CDI culture centred on revenue protection, risk adjustment, and audit readiness. The adoption of the American Recovery and Reinvestment Act of 2008, which turbocharged the deployment of electronic medical records (EMRs), further accelerated the CDI field, intertwining technology and documentation improvement in ways that continue to influence strategy today.
In Australia, however, and across other ICD-10-AM countries, our single-payer system, activity-based funding models, and public-private mix have nurtured a distinct environment - one where the philosophical and functional focus of CDI is evolving around clinical accuracy, hospital funding integrity, patient safety, and improved communication between health professionals. And so, as we consider the lessons from ACDIS and from our U.S. colleagues, we must do so with thoughtful differentiation. Below are six core contrasts in CDI practice that I believe offer deep insights into our next steps as a maturing CDI community.
In the U.S., verbal queries are discouraged by leading professional bodies, due to the risk they pose to query integrity and audit defensibility. Without a documented trail, verbal interactions may be seen as coercive or ambiguous, especially in high-stakes reimbursement scenarios. Many U.S. CDI professionals recount physicians responding with, "Just tell me what you want me to write," - a red flag in a system built on demonstrable clinical independence.
In contrast, in Australia and other ICD-10-AM settings, verbal queries are not only accepted but often seen as a crucial part of the documentation improvement dialogue. In-person or real-time communication helps build relationships, clarify misunderstandings, and foster collaborative engagement with clinicians. As long as the purpose is educational and the outcome is accurately documented, verbal interaction is a valued part of our toolkit - one that enhances documentation quality, not compromises it.
The U.S. model often treats queries as transactional tools - aimed at adding precision to documentation for coding accuracy, DRG optimisation, or audit protection. Many CDI programs measure success by query response and agreement rates, with CDI professionals seen as revenue protectors or auditors embedded in the care process.
By contrast, Australian CDI philosophy is increasingly transformational, prioritising improved documentation behaviour over individual query outcomes. Education, coaching, and sustained clinician engagement are the cornerstones of a maturing system focused on long-term cultural change. Written queries are just one component of a broader quality-driven documentation integrity effort.
The emphasis in many U.S. CDI programs is on quantifiable output: number of queries issued, turnaround time, agreement rates, and DRG shifts. These metrics offer clear reporting lines for executives but can incentivise quantity over quality - potentially undermining the more nuanced work of documentation improvement.
In contrast, ICD-10-AM countries are beginning to look beyond the numbers, focusing instead on documentation behaviour change, education uptake, and data accuracy. While response times and volumes still matter, they are balanced with deeper indicators like condition capture rates, audit outcomes, and clinician feedback. Our engagement is increasingly measured not just by what we send, but by what we change.
In the U.S., CDI professionals often perform provisional coding during record reviews. This means they are actively assigning working DRGs and even ICD-10-CM codes as part of their day-to-day role. Coders then finalise these assignments, triggering a dual-coding and reconciliation process that is resource-intensive and sometimes duplicative.
In Australia, coding responsibility is clear and segmented. Health information managers (HIMs) and clinical coders are the final arbiters of coded data. CDI professionals work in parallel, focusing on ensuring the documentation supports accurate, complete, and codable records - without performing coding themselves. This clarity enables a clean division of labor and a collaborative, rather than overlapping, model.
The U.S. CDI landscape is deeply technology-integrated. Natural language processing (NLP), prioritisation algorithms, mobile query apps, and real-time dashboards are standard across many hospitals. These tools support scale, speed, and data visibility - but they can also reinforce a transactional query culture and reduce human connection.
In ICD-10-AM countries, tech adoption is growing, but we have the chance to strike a better balance. Tools that enhance workflow and data accuracy are welcome, but not at the cost of relationship-driven engagement with clinicians. We should aim to use technology to support - rather than supplant - the human role in improving documentation and communication.
There’s no question that the U.S. has been a global leader in developing, scaling, and systematising CDI. Conferences like ACDIS Inspire showcase the enormous investment, depth of practice, and strategic innovation that define the American CDI industry. And there is much to learn - about the use of data, the role of audit, and the value of well-integrated tech solutions.
But there’s also a deeper lesson for Australia and other ICD-10-AM countries: we don’t need to mirror the U.S. model to grow with purpose. In fact, our contrasting system—less fragmented, more clinically integrated—offers a unique opportunity to build a CDI profession focused not just on reimbursement, but on patient safety, care quality, and communication.
Our path forward is one of intentional identity-building. That means forging a CDI model that enhances data integrity, reflects clinical complexity, and ensures hospitals are funded fairly - not excessively, not inadequately, but accurately.
Most importantly, it means recognising that CDI is about more than queries and codes. It’s about supporting the people and processes that ensure the patient story is told clearly, truthfully, and with the quality that every patient, every provider, and every system deserves.