CDI teams in ambulatory settings are feeling the weight of tighter regulatory demands. With more diagnoses expected to be documented accurately in less time—and with greater consequences for error—Outpatient CDI professionals are at the forefront of compliance risk and operational pressure. The shift to CMS HCC V28 has introduced a wave of complexity, shrinking the list of qualifying HCCs and tightening the rules around documentation. As if that weren’t enough, audit protocols like RADV continue to gain momentum, exposing gaps that once went unnoticed. The stakes are clear: documentation must be right the first time, every time.
What V28 Means for CDI in the Outpatient Setting
The CMS HCC V28 model reshapes risk adjustment expectations. Several long-standing HCC categories have been removed or restructured, meaning that many diagnoses which previously contributed to patient risk scores now offer no adjustment—or require more precise documentation to qualify.
Unlike past models, vague or shorthand references to chronic conditions are no longer acceptable. HCC coding now depends on documentation that clearly reflects Monitoring, Evaluation, Assessment, or Treatment (MEAT) for every reported condition. Providers must show clinical intent and relevance at every touchpoint.
This model also places greater weight on the outpatient environment. As more care shifts to ambulatory settings, the responsibility for accurate risk capture is falling increasingly on primary care, specialist, and transitional care visits. That means outpatient CDI professionals must go beyond traditional support roles and become embedded collaborators—guiding real-time documentation and championing audit resilience from the inside out.
How CDI Can Respond Strategically to Increased Scrutiny
1. Embed Real-Time CDI Support in Clinic Workflows
Waiting days—or even hours—to review charts is no longer sufficient. Real-time documentation review, in collaboration with providers during or immediately after the encounter, dramatically improves accuracy and eliminates the guesswork that can lead to risky submissions. CDI professionals need tools and training to act quickly and discreetly, enabling gentle course correction while the details are still fresh.
2. Lead the Charge on V28 Education
V28-specific training is no longer a nice-to-have. Providers are adjusting to new exclusions, hierarchical changes, and higher standards of documentation evidence. CDI teams must act as educators, translating regulatory language into practical, encounter-level guidance that providers can apply without slowing down their clinical workflow.
3. Prioritize High-Impact Encounters
Not all visits carry the same risk. CDI teams should focus resources on encounters with the greatest potential for HCC capture and audit exposure—such as annual wellness visits, chronic condition management follow-ups, and transitional care episodes. These visits are often the best chance to update the full clinical picture and recapture conditions that drive RAF accuracy.
4. Automate Where It Makes Sense
Technology can be a powerful force multiplier for outpatient CDI. Platforms that flag undocumented chronic conditions, track missed HCCs, or highlight documentation that lacks MEAT elements can save time and reduce human error. However, these tools should support—not replace—clinical judgment. The right tech stack allows CDI professionals to work smarter and prioritize better, not become data managers.
5. Partner with Coding and Compliance Teams Early
Breaking down silos is no longer optional. CDI, coding, and compliance teams must align on goals, share insights, and collaborate on chart review strategies. Regular case reviews, shared audit dashboards, and cross-functional performance metrics help ensure that everyone is pulling in the same direction—especially as audit risk intensifies.
Key Wins for CDI Teams That Adapt Early
CDI teams that proactively adjust their strategies for V28 and RADV expectations will see measurable benefits.
- Cleaner documentation reduces the risk of queries, rework, and denials.
- Provider relationships improve as CDI teams are seen as helpful allies, not compliance enforcers.
- RAF scores become more reflective of patient complexity, improving revenue accuracy and forecasting.
- Organizations are better prepared for CMS audits, with fewer surprises and stronger defense strategies.
- CDI professionals experience less burnout, thanks to workflows that prioritize efficiency and clarity over volume.
Don’t Fall Into These Common CDI Pitfalls
Even the most experienced teams can stumble during a period of transition. Some outpatient CDI programs try to replicate inpatient workflows without adjusting for the faster pace, higher volume, and lower documentation control in ambulatory settings. Others delay provider education, assuming coding teams can fix things on the back end. Still others rely too heavily on retrospective reviews, issuing dozens of queries for a visit that’s long since passed.
Perhaps the most common mistake is underestimating how different V28 really is. Without model-specific training and process redesign, teams may find themselves out of compliance—despite working harder than ever.
What CDI Leaders Can Do Now
Start by assessing current documentation workflows and identifying the points where risk is most likely to be missed. Look at query trends, claim denials, and prior audit findings to identify recurring themes. From there, build a phased plan that prioritizes the most vulnerable encounters, engages providers in real-time improvement, and leverages technology where it provides the most value.
Work closely with compliance and HIM teams to establish a shared understanding of what “audit-ready” means under V28. Make sure documentation policies are updated, query processes are streamlined, and performance metrics align with new regulatory expectations.
Above all, focus on sustainability. The pressure on CDI teams will only increase in the coming years. Building resilient, flexible, and provider-aligned processes now is the best way to ensure long-term success.
Reinforce the Value of Preparedness
Outpatient CDI professionals are being asked to do more than ever—often with less support and tighter timelines. The shift to CMS HCC V28 and the intensifying wave of RADV Audits demands precision, collaboration, and early intervention. Those who lead now, who focus on education, workflow alignment, and strategic documentation practices, will be the ones whose charts withstand scrutiny and whose teams become the backbone of organizational compliance. It’s not just about catching errors anymore—it’s about building documentation right the first time.
