2025 CDI Week Q&A preview: Denials management

As part of the fifteenth annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Payal Sinha, MBA, RHIA, CCDS, CDIP, CCS, CCS-P, CCDS-O, CRCR, CRC, director of revenue integrity, audit, and education at Montefiore Medical Center, answered these questions. Sinha is a member of the ACDIS Furthering Education Committee. For questions about the committee or the Q&A, contact ACDIS Editor Jess Fluegel (jess.fluegel@hcpro.com).

Q: According to the 2025 CDI Week Industry Survey results, about 55% of CDI programs are involved with some sort of denials management. Of those whose CDI departments are not involved in denials management at their organization, 19% of respondents said they are planning to get involved in the near future. How is your CDI team involved with denials, and for how long has it been involved? What successes and/or challenges have you experienced in that time?

A: Our CDI team has been actively involved in denials management, and more so in recent years in light of ever-changing payer guidelines. Our CDI team focuses on clinical validation denials in partnership with HIM so that our appeals can include valid clinical and coding information that will be of interest to the payer. A notable challenge has been the ongoing education needed for both providers and staff to ensure consistent documentation that supports medical necessity and coding compliance. While this requires significant time investment, it has also strengthened provider engagement and improved our overall documentation quality.

Q: When asked who in the CDI department is involved with the denials management/appeals process, almost 36% of respondents said that their CDI department had a designated denials or appeals specialist, which is a notable increase from 2024 industry survey data (29.17%). Have you noticed this type of role becoming more common in the CDI industry? Who on your team is involved with denials management and/or appeals, and what is their role like?

A: CDI involvement in DRG validation denials is likely becoming more common because these cases directly impact hospital reimbursement, quality metrics, and publicly reported data. As payers increase scrutiny on coding accuracy and DRG assignment, organizations are recognizing the value of CDI expertise in ensuring clinical documentation fully supports the billed DRG. For CDI programs deciding which types of denials to focus on, I recommend starting with a review of denial trends, financial impact, and organizational priorities. Partner closely with coding, case management, and compliance teams to identify where CDI expertise will add the most value. Begin with one or two high-impact denial types to build expertise, then expand as resources and success allow.

Q: When asked about the most common type of denials that their CDI program is involved in, 87.73% of respondents chose clinical validation. The runner-up was DRG validation, chosen by 64.11%, which was an increase of nearly 10 percentage points compared to 2024 (54.66%). Why do you think CDI involvement in DRG validation denials may be becoming more common? What types of denials does your CDI team help with, and how was that decision made? What advice do you have for CDI programs in choosing which types to focus on?

A: It is possible Medicare could make a comeback as the largest source of denials in the future, especially as Medicare administrative contractors continue to expand audit activity and refine criteria for medical necessity and coding compliance. However, private payers remain aggressive with their denial strategies, so the balance may depend on shifting payer policies and audit focus areas.

In the past year, many organizations have seen the highest volume of denials from private payers, particularly around clinical validation. We have had success mitigating these denials through proactive pre-bill reviews, targeted provider education, and close collaboration between our medical director, CDI team, and coding team. This approach has improved documentation quality, strengthened our appeal letters, and continued to reduce repeat denials from the same payers.

Q: About 85% of respondents reported that sepsis is one of their top five denied diagnoses, consistent with past years. Respiratory failure saw another small jump, from 74.02% who said respiratory failure was in their top list in 2024, to 77.61% in 2025. Encephalopathy saw a notable increase as well, chosen by 57.36% of respondents in comparison to 48.77% in 2024. Have you noted an increase of certain denials in recent years, such as those related to encephalopathy or respiratory failure? What are the top five denied diagnoses at your organization, and what about these diagnoses do you think makes them more prone to receiving a denial?

A: Yes, many organizations have observed a noticeable increase in denials related to encephalopathy and respiratory failure over the past couple of years. These conditions, along with sepsis, remain consistently high on our denial lists along with other organizations due to their subjective clinical criteria and varying payer definitions. At any organization, the top five most frequently denied diagnoses are:

1. Sepsis
2. Respiratory failure
3. Encephalopathy
4. Malnutrition
5. Acute kidney injury

These diagnoses are more prone to denials because they often rely on clinical judgment, lack universally agreed-upon diagnostic criteria, or are seen by payers as over-documented or up-coded. For example, payers may challenge respiratory failure if there is insufficient evidence of oxygenation issues or ventilatory support, or encephalopathy if baseline mental status isn’t clearly documented. To address the industry trend, we’ve focused on improving provider education around documentation specificity and aligning closely with coding and CDI teams to support the clinical validity of these diagnoses.

Q: About 18% of respondents said their program uses some form of technology to identify charts that may be vulnerable to denials, and in the free response section, many wrote that they are looking into this kind of solution. Does your program use any technology to help identify charts at risk of denial or to assist in any other part of your denials management process? If so, what advice would you give to CDI programs seeking to integrate technology into denials management?

A: We’ve integrated tools within our CDI workflow that flag documentation gaps. Additionally, we leverage reporting dashboards and data analytics to track patterns in denials by payer, diagnosis, etc., which helps us prioritize education and intervention.

For CDI programs looking to integrate technology into denials management, my advice is:

• Start with a clear goal. Whether it’s reducing denial volume, improving documentation accuracy, or streamlining appeals, define your objectives first.
• Evaluate tools that align with your workflow. Choose solutions that integrate with your EHR or CDI platform to avoid added complexity.
• Involve all stakeholders early. Collaborate with IT, coding, revenue cycle, and compliance to ensure smooth implementation and shared ownership.
• Use technology as a complement, not a replacement. Technology can flag risks, but clinical expertise and critical thinking are still essential.
• Monitor and adjust. Track the impact of the tool and refine your strategies over time based on data and outcomes.

Integrating the right technology can significantly enhance a CDI program’s ability to proactively prevent denials and strengthen documentation quality.

Q: Compared to 2024 data, there was a drop of nine percentage points among respondents reporting that their CDI program is involved in some form of denials management. Do you have any ideas about why that might be? Do you think that CDI involvement in denials is usually worth the investment for organizations, and why or why not?

A: The nine-percentage drop in CDI involvement in denials management compared to 2024 could be due to several factors. Some organizations may be facing resource constraints, staffing shortages, or shifting priorities toward other CDI initiatives like quality metrics or outpatient documentation. Additionally, some programs may have found it challenging to demonstrate a clear return on investment in denials work or may have shifted those responsibilities to revenue cycle or appeals teams instead.

Despite this decline, I believe CDI involvement in denials management is absolutely worth the investment for most organizations. CDI specialists bring clinical expertise and documentation insight that is crucial for addressing clinical validation and DRG-related denials. Their proactive reviews and documentation guidance can prevent denials before they occur, reduce appeal burden, and improve financial outcomes. CDI teams also play a key role in identifying denial trends and educating providers to strengthen documentation long-term. When strategically implemented and well-integrated with revenue cycle processes, CDI-driven denial management enhances compliance, supports accurate reimbursement, and helps organizations stay ahead of evolving payer behaviors.