To think that queries and increased case mix index (CMI) is the end-all and be-all of CDI is a fallacy.
In a recent conversation with a chief financial officer of a medium-sized hospital where a clinical documentation integrity (CDI) program was well-established, I raised the question of whether a CDI program is a true asset or a mere liability. This sparked a thought-provoking discussion, wherein I made the following compelling case that CDI programs truly fall into the liability category, as opposed to being an overwhelming asset to any organization.
CDI: The Reality of It All
CDI as a profession really began with the advent of the MS-DRG system in 1987, when Medicare began its continuous journey to update their prospective payment system and reimburse providers “more accurately and fairly.” The expansion of the MS-DRG categories into DRGs with complications and comorbidities (CCs) and major CCs (MCCs) started what has evolved into a “cottage industry” that CDI consulting companies have perfected, creating an ongoing market for their services, guiding their hospital and health system clients on how to “improve” the physician’s documentation in the name of documentation integrity and resulting reimbursement.
They have also created and continue to push key performance indicators (KPIs) that are task-based, the likes of which include number of charts reviewed, number of queries issued by the CDI staffer, number of queries responded to by the physician, and the physician query agreement rate, to name just a few. These same companies have developed and continue to push their CDI software, utilizing artificial intelligence (AI) and natural language processing (NLP) to drive efficiencies in CDI chart review, facilitating prioritization of records with the most likely opportunity for “documentation improvement” (i.e., reimbursement capture).
There is even CDI software being peddled that purports to use AI and NLP to “nudge” physicians to document a diagnosis with appropriate clinical specificity, while physicians are charting in real time. I liken this to nothing more than increasing physician administrative burden and intrusion while doing little to change overall physician behavioral patterns of documentation for the better, sustainable over time. The CDI profession has been relegated inarguably into a task-based, job-oriented activity, digressing from the original intent of the profession to drive meaningful, measurable, sustainable improvement in documentation that addresses and actually accomplishes the name change to “clinical documentation integrity.” Queries have become the hallmark of CDI programs, overlooking opportunities to attain real improvement in overall documentation quality, accuracy, completeness, and effectiveness. Measuring CDI performance by task-based activities, utilizing current KPIs, instills a sense of false attainment of progress, whereby CDI Leaders potentially mislead the C-Suite with measures that may not best support the revenue cycle with much-needed net patient revenue.
CDI: Liability Self-Perpetuation
The CDI profession with its present operational processes perpetuates the continuation of ongoing liabilities for each facility. Queries as the hallmark of CDI activity definitively carries the potential to generate additional costly clinical validation denials and DRG downgrades, pre- and post-payment, often unappealable due to lack of solid physician documentation that best tells the patient story, accompanied by clear clinical information, facts, and context. Yes, clinical indicators may support a query and the addition of a diagnosis (CC/MCC) to the record, yet the clinical story as depicted in the record does not lend credibility to the diagnosis. When it comes to outside payer scrutiny of the medical record content to validate all diagnoses in support of the assigned MS-DRG, putting it bluntly, “it is not so just because the physicial said it is.”
Within the last six months I have reviewed countless clinical validation and medical necessity denials, as well as DRG downgrades, and I cannot begin to imagine the number of records for which I agreed with the payer’s determination, mainly attributable to poor and/or insufficient physician documentation. In many of these cases, CDI intervened in some form or fashion, including review of the record with endorsement of the diagnoses documented, and/or the issuance of a query for a CC/MCC that was later refuted by the payer. Clearly, this must be considered a liability on the part of the CDI profession, reviewing a record and missing the opportunity to affect meaningful improvement in the integrity of the record. In the words of my longtime colleague Dr. Jacob Martin, a physician champion and documentation educator, queries merely generate “feel-good” money that more often than not does not materialize or may result in recoupment, resulting in “feel-bad” money.
Queries with physician agreement and subsequent coding with a higher-weighted MS-DRG do not necessarily equate to real revenue with preservation over time. What matters most to CDI is what cash is collected (and is able to be maintained) from payers. To think that queries and increased case mix index (CMI) is the end-all and be-all of CDI is a fallacy; the CDI profession must take action to transform current processes predicated upon grabbing CCs/MCCs to a more practical approach that actually focuses upon achieving clinical documentation integrity. Unequivocally, CDI is a current liability to facilities in its present format, as opposed to a revenue generator, when you consider staff salaries, benefits, consulting fees, staff education and training, and software and administrative costs associated with program operations.
More Created Liabilities
I have pointed out and written several blog posts and articles on the 2019 Medicare Fee-For-Service Supplemental Improper Payment Data Report, highlighting among many points that nearly 80 percent of improper payments made by Medicare for Part A hospital stays was attributable to insufficient documentation and medical necessity. Each of these categories are for the most part one and the same, given that more than half of medical necessity denials are avoidable with more effective physician documentation (not more documentation, but simply more effective documentation). Do take the time to check out the report, and note tables D4 and E4, which highlight the top 20 MS-DRGs associated with improper payment (CERT Report).
A reasonable question to pose to the CDI profession is how nearly 80 percent of improper payments made under the Centers for Medicare & Medicaid Services (CMS) Fee-For-Service Part A hospital setting are associated with documentation-related issues; remember, the name of the game should be “integrity,” which does not appear to materialize in the form of compliant documentation, coding, and billing. Hence my assertion that CDI creates undue liability and compliance risk, by virtue of the fact that we are failing to capitalize upon the opportunity to drive real improvement in physician documentation.
Simply stated, without establishment of medical necessity through complete and accurate physician documentation in the emergency department and history and physical (an area that is certainly within the realms of the CDI profession), CDI in and of itself is irrelevant, and does not need to get involved in CC/MCC capture.
Unrelenting focus upon CC/MCC capture creates the potential for aberrant patterns of coding and billing that are readily identifiable by payers, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and Comprehensive Error Rate Testing (CERT) contractors, to name a few entities. Data analytics and data mining of billing data are readily available capabilities that all payers and regulatory agencies, as well as Medicare contractors, take full advantage of as part of compliance and safeguarding of payments under fraud-and-abuse prevention provisions.
It is very disturbing and perplexing to me when I come across hospitals with DRG 470/469-sepsis without or with MCC as their top DRG every month, with DRG 177-respiratory infection and inflammation with MCC as the No. 2 DRG, consistently. In summary, the CDI profession is potentially increasing unnecessarily compliance liability through the query process and the focus upon reimbursement, without affecting improvement in the supporting physician documentation.
Anytime one focuses upon outcomes without improving necessary processes integral to achieving outcomes, there is always going to be inherent undue risks, in this case significant compliance and financial risk.
I submit to all CDI professionals that change in current operational CDI processes is a must for survival of the profession, as well as the financial survival of the healthcare entities with which we are affiliated. We must recognize and act upon the continued liability scenario created by reliance upon CDI consulting company guidance that promotes CC/MCC capture only as the foundation for CDI processes.
I am fully supportive of hospitals and health systems being reimbursed for the care they provide by focusing upon doing the right thing, taking action to achieve clinical documentation excellence through implementation of processes that are designed to generate optimal compliant revenue with optimal physician documentation.
Asset versus liability: the choice is yours.