Measuring Query Impact: Are Your CDI Processes Preventing Denials?

As Clinical Documentation Integrity (CDI) departments transition from a revenue enhancement tool to a revenue integrity tool, the industry needs to rethink query metrics.

Do high query rates, high response rates and high agreement rates have the same impact in today’s reimbursement environment? How are these metrics related to medical necessity, clinical validation, and DRG validation denial rates?

SIt is time for the industry to shift the conversation from “How many queries were sent” to “Did the query result in a clean claim?” In other words, was the claim accurate, clinically supported, and defensible on appeal, even if it results in a lower-weighted DRG being billed.

When CDI reviews a record, the review should reduce, not increase, downstream risk including the need for a second level review. At the very least, the work of concurrent clinical documentation integrity specialists (CDISs) should reduce the need for and complexity of backend processes. When a record reviewed by CDI results in a denial, it should be reviewed to determine if the denial is valid, or if it could have been prevented through improved documentation.

If querying did occur, the analysis should include the quality of the query itself, including whether it clearly articulated clinical criteria, conflicting documentation, or organizational standards. When a denial occurs for a condition that was clinically reviewable during the CDI process, the failure is not only at the payer level but also reflects an opportunity for CDI process improvement.

One of the largest contributors to shrinking hospital margins, according to the American Hospital Association (AHA) in their 2026 Cost of Caring report, is increasing costs per patient stay driven by increased administrative overhead. According to the AHA, “Hospitals also are facing rising administrative costs tied to commercial insurer requirements that add complexity to delivering and paying for care.” Activities like “prior authorization, claims denials, repeated documentation requests, and evolving billing and coverage rules require hospitals to staff large billing, coding, utilization management, and appeals teams,” according to the AHA.

The AHA reports that, “in 2024 the average hospital employed about 64 administrative and billing staff dedicated to these functions” accounting for about “6.5% of total hospital employment.” Higher patient acuity results in more complex patients leading to higher denial rates that compound the growing pressure on hospital resources. The bottom line according to the AHA is, “In an environment where margins are thin, these costs and delays reduce hospitals’ ability to invest in workforce, technology and capacity.”

As I discussed in last week’s article, CDI departments need to focus on preventing revenue leakage, support defensible billing, and mitigate financial risk. CDI departments need to examine how queries contribute to these areas even if it results in the removal of a complication/comorbidity from a claim, thereby lowering the relative weight of the billed MS-DRG.

Preventing denials results in cost savings.

To be clear, I am not suggesting that hospitals should be denial avoidant. The goal is to be compliant. Engaging in compliant practices ultimately results in high overturn rates because the payers will not be able to defend their actions. What are compliant practices? If a hospital has an organizational definition for a particular diagnosis and a provider documents the condition without meeting the required threshold, issue a clinical validation query.

A reviewed chart that later denies for an addressable documentation or clinical validation issue represents a missed opportunity. As CDI departments redefine success through the lens of revenue integrity, accountability must extend beyond query volume and agreement rates.

CDISs should be expected to identify and address documentation risks that contribute to denial even when doing so results in a lower-weighted DRG.

The measure of success is not how many queries were sent, but whether CDI intervention helped deliver a compliant, defensible claim.