Ambulatory CDI programs require a distinct operating architecture

The team at Reveleer attended ACDIS 2026 and listened in on a session, “Empower CDI: Bridging Acute and Ambulatory Care for Optimal Outcomes”. Optum consultants Sally Hart and Jill Lindsay led the session, presenting to a room that, by their own opening poll, had almost no attendees currently operating in ambulatory programs. Hart and Lindsay brought inpatient, ambulatory, and pediatric CDI experience accumulated across health systems of varying size and maturity. The session covered the state of the industry, the structural differences between inpatient and ambulatory CDI, and the operational architecture that separates programs capable of scaling from those that stall after a pilot. The findings merit attention from anyone building or evaluating an ambulatory CDI program.

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The documentation gap is quantified, and the financial exposure is direct

Hospital operating margins stabilized in 2025, with median performance holding in the 2–3% range, leaving limited room for error as financial pressures persist. Denial rates continue to rise as payers deploy automated claim review processes, increasing the likelihood that providers absorb or delay reimbursement.

Within Medicare Advantage, a related but distinct pressure is emerging around documentation integrity. A 6.09% improper payment rate in Medicare Advantage reflects the extent to which submitted diagnoses are not supported by sufficient documentation. Federal audit activity continues to reinforce this pattern, with oversight focused on whether diagnoses used for risk adjustments are fully substantiated within the medical record. Incomplete condition capture suppresses RAF accuracy, while diagnoses that do not meet documentation requirements introduce measurable RADV audit and repayment risk.

Version 28 of the HCC model, now fully in effect after a multi-year transition, reduced the eligible ICD-10 code set from approximately 9,800 codes under V24 to 7,700 under V28. All HCC status resets on January 1, requiring every chronic condition to be recaptured within the calendar year. The RAF score for each patient reflects only what was documented across that 12-month window, making documentation completeness a direct determinant of reimbursement accuracy and a primary driver of RADV audit exposure. That is the environment ambulatory CDI programs are built to address, and it is also the environment that exposes programs built on the wrong operational model.

Ambulatory CDI demands a proactive operating model inpatient programs were never designed to produce

During the ACDIS session, Lindsay made the argument for better CDI architecture directly. The ambulatory environment demands a fundamentally different documentation model, and the structural reasons are specific enough to matter for program design decisions.

In inpatient CDI, a specialist has days to work a chart, track down a provider, and build a documented case. However, in ambulatory settings, providers see three to four patients an hour. The pre-visit review window runs three to five days. The point-of-care window closes when the patient leaves the room. Under those constraints, pre-visit nurses must review records and surface documentation gaps before the encounter, point-of-care prompts must integrate into the provider's clinical workflow without adding friction, and post-visit coders must confirm that every submitted diagnosis meets M.E.A.T. criteria before the claim is submitted.

Hart was specific on the middle stage. Providers will deprioritize query processes that interrupt their clinical flow, and a CDI program that competes with how a provider operates will lose ground quickly. Those three stages must function as a governed pipeline. Programs that treat them as sequential handoffs accumulate errors at every transition and produce the documentation gaps that surface later under audit.

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You can't just show up on a Monday morning and say we're doing this. The provider doesn't know who you are, and you're already behind the curve."
_{-Jill Lindsay, Clinical Director, Optum}

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The six operational pillars of ambulatory CDI implementation

Hart and Lindsay organized their implementation framework around six operational pillars, and their presentation made clear that the absence of any one creates a structural gap the program will struggle to recover from at scale.

1. Defined mission, vision, goals, and department structure

Establish clear financial and quality objectives for your ambulatory CDI program.

2. Staffing, productivity, and CDI roles

Align team responsibilities with program goals by defining FTE requirements, competency expectations, and a structured onboarding and training framework.

3. Efficient and consistent process flow

Standardize CDI and coding workflows including query processes and NLP utilization so every team member can execute consistently.

4. Strong relationship and rapport

Build cross-functional alignment between CDI specialists, coders, quality teams, compliance, and physicians through shared goals and ongoing education.

5. Continuous performance accountability

Track program impact through defined metrics and real-time monitoring, fostering a culture of proactive documentation improvement and measurable outcomes.

6. Consistency across care settings

Unify ambulatory CDI efforts with key departments and stakeholders to drive performance across both fee-for-service and value-based care arrangements.

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A defined mission and clear goals keep a cross-functional program coherent. Ambulatory CDI spans compliance, population health, revenue integrity, coding, and clinical operations simultaneously, and without a shared framework those functions optimize independently. Staffing and productivity models must be calibrated to the specific operating environment, with technology choice, patient population, and visit type mix all factored in before a staffing ratio is set. Efficient and consistent process flow requires the three-stage pipeline to operate as a governed sequence, with standardization where achievable and defined escalation paths where documentation gaps exceed the scope of the normal workflow.

The remaining three pillars address the human and governance dimensions of program sustainability. Provider relationships are a structural program requirement. Trust must be built over time through consistent, non-punitive engagement, monthly check-ins framed as support, and specialty-specific education grounded in comparative performance data. Hart observed that providers are competitive, and that scorecards delivered consistently and respectfully change behavior over time. Continuous performance accountability requires KPIs defined at the appropriate leadership level, with operational, executive, and staffing metrics kept distinct so that each serves its intended audience clearly. Consistency across care settings ensures the ambulatory CDI program integrates with institutional priorities and coding governance structures, because programs that run as parallel functions generate compliance exposure at every handoff point between workflow stages.

Pilots are a diagnostic requirement, and problem list governance is a distinct operational challenge

Organizations that move directly from blueprint to full rollout accumulate workflow failures they will only identify once those failures are embedded across the program. Hart described a three-month pilot structured around sites managed by a single practice manager, which streamlined communication and accelerated the feedback loop. Even within that structure, the team was simultaneously testing workflows, onboarding staff, training pre-visit nurses, building post-visit coding processes, and resolving EHR configuration issues in real time. In the longer case study presented, the arc from initial planning to full optimization spanned six years, with meaningful program activity beginning several years into that timeline. That arc reflects the infrastructure development, stakeholder alignment, and iterative refinement a reliable program requires. A pilot is a necessary mechanism through which a program learns what it does not yet know about itself.

Problem list governance is a distinct challenge. Physicians annotate diagnoses in the problem list with clinical notes carrying longitudinal patient history, and modifications require physician involvement to preserve that context. Hart noted that CDI teams should treat the problem list as a controlled governance domain, require physician leadership involvement in any modification process, and build quality assurance structures into every change.

Compliance architecture and the contracting regulatory window

A Q&A exchange during the ACDIS conference surfaced a compliance question around how HCC alerts within the Epic EHR could be considered compliant when they are, by design, surfacing revenue-relevant diagnoses to providers. Hart's answer turned on the evidentiary standard. Compliance depends on whether documented clinical support exists for the condition being surfaced. Alerts grounded in prior documentation and clinical indicators meet that standard. The same evidentiary standard that governs inpatient queries governs ambulatory queries, and post-visit coders must have the authority and training to add or remove codes based on documentation review at the encounter level.

Hart closed with a reference to TEAMS bundles and the expansion of risk adjustment methodology into fee-for-service Medicare. The enforcement pressure has yet to fully materialize, and urgency across the industry reflects that lag. Health plans and health systems that build ambulatory CDI programs on governed clinical workflows, compliant query structures, and auditable documentation trails will be positioned to absorb that expansion. Programs built under audit pressure rarely achieve the operational discipline the environment will require.

Reveleer supports provider organizations, enablers, and health plans in building compliant, scalable ambulatory CDI programs grounded in clinical governance and audit-ready workflows. Connect with our team to assess your current documentation practices and identify where a structured CDI program strengthens capture, reduces audit exposure, and improves RAF accuracy across your patient population.

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