Clinical Documentation Improvement Request

Clinical Documentation Improvement Request — Form Fields

This healthcare template includes 11 fields. Coders and CDI specialists submit documentation clarification requests to physicians for more specific coding. Free to customize and use on ZenBuild.

• CDI Specialist Name (text, required)
• Email Address (email, required)
• Patient Account Number (text, required)
• Attending Physician Name (text, required)
• Date of Service (text, required)
• Request Type (dropdown selection, required) — options: Principal Diagnosis, Secondary Diagnosis, CC/MCC Capture, Procedure Specification, POA Status, Discharge Status
• Clinical Documentation Concern (long text, required)
• Suggested Diagnosis or Clarification (text, required)
• Supporting Clinical Evidence Present? (dropdown selection, required) — options: Yes, Needs Physician Confirmation
• Query Format (dropdown selection, required) — options: Open-Ended, Multiple Choice
• Urgency (dropdown selection, required) — options: Routine, Before Billing, Urgent