As the provision of healthcare changes, so too must clinical documentation improvement.
I have always been convinced of the strong capabilities of current clinical documentation integrity (CDI) initiatives to achieve tremendous improvement in the completeness and quality of documentation and communication of patient care in the electronic health record.
Today’s work week activities simply reinforced my conviction that there is ample opportunity for CDI as a profession to enhance current processes by addressing the main limitation that is preventing the industry from unlocking and achieving its potential. The primary constraint of CDI centers around the overreliance on the retrospective, reactive, repetitive transactional query process that fails to embrace the concept of physician education and overall behavioral modification in improving patterns of physician documentation.
Allow me to delve into some further thoughts from my most recent CDI-related activities.
Measuring and Assessing True Clinical Documentation Integrity
Traditional key performance indicators (KPIs) utilized in clinical integrity programs to showcase measures, performance, and success are predicated upon statistics: numbers derived primarily from the query process. Such KPIs include case-mix increase, complication, and comorbidity (and major complication and comorbidity), or CC/MCC, capture rate, overall query rate, physician query response rate, physician query agreement rate, and observed versus expected mortality rate.
These represent mere data points with little if any relation to quality and completeness in the communication of fully informed, coordinated, patient-centered, quality-focused care supportive of net patient revenue.
The disconnect between current CDI’s KPIs and achievement of recognizable, meaningful improvement and integrity of documentation can be readily identifiable if one review most inpatient medical record encounters. Insufficiencies and poor physician documentation can be easily seen in most instances, beyond lack of specificity in diagnoses, documentation of symptoms versus provisional or definitive diagnoses, treating of abnormal findings versus diagnoses, etc., to name just a few issues. These documentation deficiencies are typically addressed through the query process. I am referring to insufficiencies and poor documentation directly impacting communication of patient care, aside from diagnoses, elements such as the following:
- Emergency department documentation that fails to depict a clinically unstable patient at the conclusion of the workup and treatment, and/or clinical concerns warranting and justifying hospital level of care.
- Insufficient history of present illness (HPI), with too much emphasis on the “past illness” versus the “present illness.” There are eight elements of an HPI associated with reporting the patient’s clinical acuity and severity of illness, all instrumental in reflecting the patient’s story in enough detail to help establish medical necessity for the hospital level of care. Often, the HPI is woefully inadequate, showing a patient with shallow complaints, and responses to investigation of the patient story that fails to clearly coincide with the physical exam, clinical findings, and assessment. Medical necessity is also called into question when the HPI is insufficient.
- Assessment/clinical impression with diagnoses and/or diagnosis specificity that cannot be easily traced back to the patient’s reported chief complaint or signs and symptoms, as recorded in the HPI. Recently, I reviewed a case in which a patient presented with acute encephalopathy documented in the assessment when the HPI did not describe a clinical picture of a confused or delirious patient. The physical exam constitutional recorded that the patient was “alert and oriented … in no distress, resting comfortably in the bed talking to wife.”
- Progress notes that do not include a chief complaint and status update of the patient’s clinical condition and progress towards discharge and the discharge plan. Often, the progress note consists of a recapitulation of previous progress notes, with the inclusion of information copied and pasted, sometimes irrelevant for that day, contextually incorrect, or clearly inaccurate. Case in point: a physician was recently queried by the CDIs for clarification of whether the patient’s condition of rhabdomyolysis was ultimately ruled out. The physician responded that the rhabdomyolysis was indeed ruled out, yet the residents continued to copy and paste the rule-out condition for the next five days’ progress notes.
Speaking of insufficient and/or poor clinical documentation, the Centers for Medicare & Medicaid Services (CMS) recently released the 2018 Improper Payment Supplemental Data report, which makes for great reading. The 2018 improper payment error rate stands at 8.1 percent, translating to $31.6 billion, in comparison to last year’s rate of 9.51 percent, or $36.21 billion in improper payments.
Approximately 84 percent of improper payments in 2018 were attributable to insufficient documentation or establishment of medical necessity. Focusing just upon the hospital inpatient setting, the calculated improper payment rate stands at 4.29 percent, with $4.96 billion in improper payments.
The majority of medical necessity denials consistently identified by the Comprehensive Error Rate Testing (CERT) contractor in its annual work is attributable to insufficient documentation. Sufficient documentation does not equate to more documentation; instead, it equates to more effective documentation that effectively communicates the patient care. Fundamental to the role of CDI is affecting positive change in documentation to the extent that the records describe the patient’s clinical story from the time the patient presents to the emergency department (ED) to the time the patient is discharged from the hospital and the discharge summary is completed.
A realistic starting point for CDI to include as part of any chart review is documentation of the patient’s chief complaint and HPI as recorded in the ED documentation and admission. My approach to chart review when perusing the ED documentation is to validate whether the documentation clearly indicates what is wrong with the patient, how it manifested, and what it looked like. If the story does not depict these elements clearly, there is opportunity to address the insufficiencies in documentation with the physician, working in tandem with the facility’s physician advisor and case management/utilization review staff.
Insufficient Documentation Versus Medical Necessity: Improper Payment Categories
The CERT contractor improper payment reporting calculations are broken down into five specific categories:
- No Documentation
- Insufficient Documentation
- Medical Necessity
- Incorrect Coding
Let’s focus on insufficient documentation and medical necessity for discussion of improper payment in the hospital setting, as defined by the CERT contractor:
- Insufficient Documentation
- The medical documentation submitted is inadequate to support payment for the services billed; or
- The CERT contractor reviewers could not conclude that the billed services were actually provided, were provided at the level billed, and/or were medically necessary; or
- A specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety
- Medical Necessity
- The CERT contractor reviewers received adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies
Addressing Insufficient Documentation and Medical Necessity
The only foreseeable means for CDI as profession to effectively and realistically address insufficient clinical documentation and issues of medical necessity is to recognize the limitations of present-day CDI processes relying primarily on the query process. Queries should be just one tool in our arsenal that can be readily adopted to educate clinicians on the standards of documentation and communication of patient care. We must forge strong collaborative working relationships with our physician advisors and case management/utilization review staff to promote the record as a communication tool versus a reimbursement tool that serves the physician, the patient, all relevant healthcare stakeholders, and ancillary functions dependent upon the medical record. Capturing diagnoses through the query process, while important, does not negate the responsibilities of CDIs to achieve integrity in the record, consisting of ensuring adequate documentation, to the extent that any person reviewing the record can quickly understand the patient’s clinical condition, current management, and where the physician is going, from a management and plan-of-care perspective. This is quite frankly not a component of current CDI processes, and until it becomes reality, insufficiency and medical necessity will remain a major challenge at most facilities.
Allow me to leave you with a vision of CDI that a physician educator and advisor and I have drafted for your consideration in transforming CDI to achieve strong performance with purpose. To achieve the highest order of specific, accurate, detailed medical documentation, whereby ensuring the most precise final coding, so that the institution receives the optimal and appropriate reimbursement to which it is entitled, based upon care provided and resources consumed, the goal must be:
- To produce a medical record, which is the most efficacious communication tool for all healthcare providers rendering care in each case;
- To provide accurate, specific, detailed medical documentation to achieve enhanced patient safety, as well as efficiency in effectiveness of care;
- To provide information for external reviewers of all types, free of ambiguity, inconsistency, or clinical incompleteness; and
- To provide a medical record that is defensible relative to external audits.