Clintegrity CDI

Increasing documentation accuracy for physicians

Comprehensive CDI solutions with guaranteed results

Based on over 20 years of success, Nuance’s Clintegrity® CDI is a proven, fully managed end-to-end clinical documentation improvement program backed by the J.A. Thomas Compliant Documentation Management Program® (CDMP®) that touches all the critical aspects of your institution's clinical documentation process. Our services and technology help you achieve an Advanced Practice CDI™ program, one that ensures high quality documentation in all care areas in your healthcare system, coordinating the efforts of your clinicians and improving quality across the continuum of care. Beginning with an initial assessment of your records and documentation needs, our team of experts will help you identify clear, measureable objectives for your CDI program. We will help manage every aspect of implementation from customizing and integrating the technology tools to ensuring your physicians, nurses, coders, and administrators understand the program and are successfully using it. Nuance will work with you to continually monitor and manage the program to make sure it meets the objectives your organization has set.

Clinical Documentation Improvement Solutions

Expertise and technology to help you establish an Advanced Practice CDI™ program

Nuance’s Clintegrity CDI is a premier clinical documentation improvement program backed by the J.A. Thomas Compliant Documentation Management Program® (CDMP®), with a fully managed, end-to-end improvement program that touches all the critical aspects of your institution's clinical documentation process.

Clintegrity CDI normally pays for itself in a matter of months as it helps you:

Improve Documentation

Unlike retrospective coding-based programs, Clintegrity CDI gives doctors and nurses education, strategies, and tools that allow them to accurately document each case from the moment a patient enters the hospital.

Improve CMI

Our program gives you a concurrent, clinical process that accurately captures compliant documentation language, complexity levels, and severity levels and ensures that they are reflected appropriately in your Case Mix Index.

Ensure Compliance

All our documentation strategies are fully compliant with The Coding Clinic and ICD-10 Official Guidelines. With Clintegrity CDI, every record contains the compliant language necessary to support appropriate reimbursement and avoid the loss and risk associated with non-compliance.

Improve Quality Core Measures

Clintegrity CDI Quality helps you identify cases subject to quality core measures in real time and impacts and improves core measure reportable data, enhancing your competitive positioning.

Ensure Appropriate Reimbursements

The more complex and severe diagnoses you manage, with appropriate documentation, the higher your CMI. And the higher your CMI, the better your reimbursement. Clintegrity CDI maximizes appropriate reimbursements by improving your documentation. It also protects you against the risk of RAC audit liability.

Ambulatory Services

Mitigate risk across your organization; thrive in value-based payment models

Healthcare reform has resulted in fewer people being treated in an acute care hospital setting in favor of lower-cost outpatient or ambulatory settings. It also directs that reimbursement for patient care be tied to quality or a value-based model, rather than the traditional fee-for-service structure.

Government officials are accelerating the shift from volume to value-based payments with a goal of building a healthcare delivery system that improves quality, affordability and access to care. This shift requires health system financial leaders to manage novel and increasingly complex care delivery and payment models while straddling between two disparate payment systems.

Healthcare executives must rethink their approach to clinical documentation improvement (CDI) to effectively address these challenges and mitigate the risks and costs that can result if they fail to protect revenue – and patients – by overlooking the significance of quality documentation.

Clintegrity CDI Ambulatory Services

Drawing on more than 20 years of clinical documentation expertise, Nuance’s J.A. Thomas & Associates (JATA) approach to Advanced Practice Clinical Documentation Improvement™ spans across the care continuum including physician offices, hospital outpatient departments, and ambulatory surgery/care centers. Our comprehensive ambulatory consulting services provide an end-to-end approach touching all critical aspects of clinical documentation, coding and billing processes to ensure compliance and revenue integrity.

Clinical Documentation Improvement, Compliance and Revenue Integrity

We understand CDI in the ambulatory setting is complex. But the rewards of taking on this challenge are critical, not only improve CDI, but to assure compliance and revenue integrity. Our team provides expert consulting services in each of the following areas and to guide your journey.

Provider Professional Services
  • Hospital/health system employed physician group practices
  • Private, independent physician group practices
Hospital Outpatient/Ambulatory Surgery Center Services (APC/ASC)
  • Hospital-based outpatient departments, clinics or centers
  • Community-based ambulatory treatment, surgery and diagnostic procedure centers
Risk Adjustment (RA) Payment Methodologies
  • Hospital/health system that owns a Medicare Advantage (MA) health plan, employ physicians with MA contracts that include RA score incentives, or that participate in an ACO
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Our process


Getting the assessment right is key to clinical documentation improvement. That's why we kick off every project with a 3-4 day clinical evaluation. We bring in a team of clinical and coding professionals to study a statistically significant sampling of your DRG-based records. They closely evaluate how admissions are being categorized according to diagnosis-related groups.

We also bring in our own physicians to meet with key members of your medical staff. They explain how the program works and make the clinical case for Clintegrity CDI to these members. Our physicians address what the expectations are, how the program benefits doctors, and how Clintegrity CDI helps improve performance measures. This way, physicians clearly understand the program from the very beginning.

With a proper assessment in place, we can accurately project the impact our Clintegrity CDI program will have on your CMI. Using these projections, we can guarantee the results of the program. This gives you a clear picture of the project outcomes before the implementation even begins.

Putting our program into practice

Implementing Clintegrity CDI is an in-depth process. That's why we work closely with you through every step. Our Clintegrity CDI team comes on site to help put the program in place and guide you through the entire implementation. Here's a brief overview of what's involved.

Comprehensive pre-planning

We provide the tools, templates, best practices, and everything else needed to prepare for a smooth and successful implementation. This includes on-site and off-site guidance and discussion to customize your program, as well as hands-on assistance with testing and interviewing as you hire your Clinical documentation improvement team.

Peer-to-peer education

Our physicians, nurses, and coders work directly with yours to ensure an effective skills transfer. We provide clinically relevant examples and on-the-floor clinical rotations where our experienced professional staff model the Clintegrity CDI process. We educate all relevant team members on the use of our Clintegrity CDI software and tools.

Customized physician education

Using clinically relevant examples in the hospital and in your doctors' offices, we clearly demonstrate to your physicians how each of them can personally benefit from learning and practicing Clintegrity CDI. Our physicians and Part B experts also provide tailored education for large and small groups.

Advanced documentation education

We work closely with your hospital's Clinical Documentation Specialists and HIM Coders to educate them on our 720+ documentation strategies. This involves a combination of formal classroom education and hands-on training. We demonstrate the outstanding results of Clintegrity CDI through multiple clinical rotations, giving your team a solid understanding of how clinical documentation improvement leads to improved CMI.

Clintegrity CDI software and tools

We provide state-of-the-art tools and technology, to leverage your team's clinical intuition and support proper documentation. Developed by practitioners, our software is continually updated with the latest documentation strategies and Coding Clinic guidelines. It enables your team to concurrently capture quality core measures and appropriate levels of severity, and enables real-time tracking against best-in-class benchmarks. We also provide other tools, templates, manuals, and pocket guides customized by specialty and roles as needed.

Real-time monitoring

We maintain constant, close monitoring to ensure that the program is being implemented successfully and is delivering results according to plan. This helps to keep everyone on the same page and avoids surprises along the way.

Ongoing support ensures long term CDI success

We stay closely involved after the implementation has been completed to ensure the sustainability of the program. This includes ongoing monitoring, continuing education, and regular evaluation and adjustment. We make sure your physicians and Clinical Documentation Improvement team stay up to date with the latest regulatory guidelines as well as the newest strategies for documentation improvement.

Our ongoing maintenance program includes:
  • Two to four on-site visits in the first year
  • Monthly results monitoring
  • Telephone support for physicians, clinicians, and coders
  • Tech support for Clintegrity CDI software and tools
  • Annual CMS changes education
  • Customized on-site training (including clinical rotations)
  • Regular software updates (3x per year) to keep up with changing regulations and add extra functionality.
  • Seminars, e-learning, and peer-to-peer mentoring for physicians (including special programs for resident hospitalists and physician champions)
  • WebEx recorded presentations on special topics, strategies, and clinical conditions
  • Continuing education and training for new employees

Extended Services & Education

Your Clinical Documentation Improvement program plays a strategic role in your healthcare system and your CDI program staff is critical to your success. Help address gaps in coverage and turnover and enable your staff to maintain confidence and peak performance with expert guidance with additional services to help maintain your Advance Practice CDI™ Program.

Interim Staffing

The unique skillset and expertise needed to fill Clinical Documentation Specialist vacancies or to augment staff during CDI program implementation can be difficult to find. We can help. Our expert consultants are trained with the JATA Compliant Documentation Program methodology to help deliver Advanced Practice CDI standards for productivity, clarification, physician response and concurrence rates and coder agreement rates. We can fill temporary position vacancies or augment your staff during an implementation, providing guidance and support for your CDI program.

Record Review

A concentrated review of certain charts to help address problem areas and identify areas for improvement. Our expert consultants can help you strategize how to address audit challenges or proactively determine ways to expand your current program.


Expert training for your team customized to address any knowledge gaps, staff turnover, or changes in industry regulations to help keep your staff and program on track and moving ahead. Didactic training sessions geared towards the adult learner along with direct access to our expert consulting team. A great investment to keep your staff sharp and engaged.

Physician Day

Our physicians work directly with yours to ensure an effective skills transfer. We provide clinically relevant examples and on-the-floor clinical rotations where our experienced professional staff model the Clintegrity CDI process. Customized physician education can help address knowledge gaps and turnover. Using clinically relevant examples in the hospital and in your doctors' offices, we clearly demonstrate to your physicians how each of them can personally benefit from learning and practicing Clintegrity CDI. Our physicians and Part B experts also provide tailored education for large and small groups.

Clinical Rotations

Targeted hands on evaluation of staff performance and program operations to address challenges and areas for improvement. Our expert consultants will assess CDS team capabilities ad develop expectations to quantify performance. A detailed evaluation and close out are provided to the CDS Director at the end of the rotation. Our approach evaluates performance based on best practice recommendations, knowledge application and productivity in support of an Advanced Practice CDI program.

Point-of-entry program

The best way to get the record straight - right from the start

As more and more patients are admitted through your Emergency Department, accurate documentation is becoming critically important. Due to the complexity of ED cases, the hectic work environment and the need to make rapid decisions, in many cases patient acuity is inaccurately reflected by under-documentation of the patient's clinical situation. Staff may accurately document the injury that brought the patient in, but miss secondary diagnoses and/or pre-existing conditions. What's more, a problem list isn't usually created until the patient is moved onto the floor...if ever. Improving the quality of the clinical documentation promotes better communication and creates an opportunity to positively impact clinical outcomes.

Nuance has developed a powerful solution and a new clinical staff position to help you ensure better clinical outcomes and accurate reimbursement.

The solution: Clintegrity CDI Point of Entry Program

Because documentation of critical information starts in the Emergency Department, the Point of Entry program starts there too - evaluating the severity of illnesses, assessing present-on-admission (POA) conditions, determining patient status (observation or inpatient), ensuring compliance with quality core measures, creating a problem list at the point of entry, and enabling more accurate documentation. The Point of Entry program builds on the foundation of Clintegrity CDI; and takes it even further, providing comprehensive clinical integration management.

New role: Clinical Integration Specialist

With this new solution comes a new clinical role - the Clinical Integration Specialist (CIS). This individual works closely with your clinical team to ensure all clinical observations are documented appropriately from the ED to discharge.

Your CIS is trained to:
  • Perform hands-on patient assessments
  • Identify and secure documentation of POA conditions
  • Assist with quality indicators such as core measures and patient safety indicators
  • Establish a problem list at the point of entry
  • Facilitate accurate, compliant clinical documentation by providing concurrent support to physicians
  • Review medical records for completeness and accuracy
  • Maintain liaison with ED and inpatient case manager and CDS


  • How CDI impacts quality ratings

    In this webinar replay, see how clinical quality outcomes data (pre- and post-CDI implementation), provide insight into the value of measuring CDI efforts' impact on overall quality ratings, including expected mortality and inpatient quality indicators.

  • CDI Success: CoxHealth

    In our On-Demand webinar, “Initiatives That Drive Quality Performance and Financial Reimbursement,” Angie Curry, Corporate CDI Manager at CoxHealth, discusses how to build a successful CDI program.

  • CDI Outside Inpatient Walls: Bolstering Compliance and Revenue Integrity

    The On-Demand Webinar addresses clinical documentation challenges and aims to mitigate the risks and costs that can result if providers fail to adopt effective Ambulatory CDI programs.



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Clintegrity will help your organization quickly generate substantial revenue and operating savings by ensuring your clinical documentation chain is accurate, sound and fully adopted by physicians.

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Call 1-877-805-5902 to speak to a clinical documentation specialist today.
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