CDI, when properly performed, supports the ancient physician oath, “First, do no harm.” 

Clinical Documentation Improvement Specialists(CDISs) play a vital role in the overall scheme of healthcare delivery through affecting measurable meaningful improvement in the quality, completeness, and accuracy in the telling of the patient story.

The major beneficiaries of sound documentation of patient care are the patient and the physician, in the form of effective communication for all relevant healthcare indirect and direct stakeholders including case management, utilization review/management, quality, safety, compliance, and third-party payers. Good documentation serves to further and facilitate the right care at the right time for the right reason in the right venue with the right clinical judgment and medical decision-making with the right plan of care. The clinician’s ability to understand, describe, tell, and show the complete and entire patient story supports the arrival of accurate conclusory diagnoses and appropriate treatment.


Limiting CDI Focus Upon Diagnoses—Not Doing Justice to Patients

Limiting CDI’s focus upon diagnoses capture serves to detract from patient advocacy in a wide variety of ways. Take, for instance, subscribing to the philosophy of doing no harm to the patient. The Agency for Healthcare Research and Quality’s National Strategy for Quality Improvement in Healthcare should be the role model for the clinical documentation improvement industry. At its core, the National Quality Strategy pursues three broad aims (National Quality Strategy):

  • Better Care: Improve the overall quality by making healthcare more patient-centered, reliable, accessible, and safe
  • Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher quality care.
  • Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

CDISs’ duties and responsibilities in chart review are performed primarily in the inpatient setting. Our duties and responsibilities entail reviewing a chart for documentation enhancement opportunities centered around clinical diagnoses specificity capture, present on admission indicator clarification, and appropriate and accurate patient safety indicator reporting. While these elements are of critical importance to patient care and the revenue cycle, our priority in chart review should be the patient, first and foremost.

The guiding principle of CDI as a whole should be affecting positive change in physician behavioral documentation patterns that is sustainable to the mutual benefit of the patient and the physician as an integral and fundamental to a strong ongoing physician-patient relationship. An offshoot of robust documentation that fulfills the physician’s obligation to understand and tell the entire patient story to the extent the next physician can pick up the patient care where the first physician left off is the delivery of patient-centered quality-focused outcomes-based cost-effective care. These latter points are where the rubber meets the road from a clinical documentation improvement perspective.

I have always said and thought that clinical documentation improvement specialists have an inherent duty and responsibility in collaborating and partnering with physicians to enhance the communication of patient care, not the quantity of the documentation but the quality of the documentation, for purposes of insuring the delivery of high-quality fully informed coordinated care.

The delivery of high-quality fully informed coordinated care is predicated upon providing the right care at the right time for the right reason with the right clinical judgment, medical decision-making, clinical rationale and thought processes. My contention of CDI playing a major role in partnering with physicians from a documentation reporting perspective in achieving timely delivery of care in the right setting for the right reason was reinforced when I read a recent article in the Spring 2018 KEPRO Case Review Connections titled, “Hospital Discharge Appeals.”


When the Entire Patient Story Comes to Roost

Medicare beneficiaries in the hospital inpatient setting have specific appeals rights related to physician discharge decisions. If the beneficiary believes he/she is being discharged too soon, he/she may invoke designated appeal rights administered by the Beneficiary and Family Centered Quality Integrity Organization (BFCC QIO), seeking an outside reviewer’s determination of the clinical legitimacy of the discharge by the hospital as evidenced by the physician discharge order. Within two days prior to discharge, the hospital case management representative is required to present to the beneficiary an Important Message from Medicare which contains and outlines the beneficiary’s rights for appealing a planned discharge from the hospital. Without going into all the details, when the beneficiary invokes his/her appeal rights the hospital is required to forward the hospital record within a tight timeframe to afford the BFCC QIO’s expedient review and rendering of decision on the physician-driven appropriateness of discharge. The Case Review Connections article points out and reminds the hospital of the necessary parts of the record to send into the BFCC QIO to facilitate the rendering of an accurate appropriateness of discharge decision. Here are the necessary elements of the record:

Reminder: When a discharge appeal is requested from your facility, please send KEPRO the following documents:

  • Copy of the Important Message from Medicare (IM) 

  • Copy of the Detailed Notice of Discharge (DND) 

  • Copy of the beneficiary’s medical record from the last 3 days including: 

  • Emergency department/admission records

  • Physician progress notes

  • Social services/case management planning notes

  • History and physical

  • Nurses notes

  • Ancillary results

  • Physician orders

  • Surgical reports (if applicable)

  • Consults

  • Inpatient order and certification

  • Physical therapy/occupational therapy evaluation and notes, if acute rehab

  • Face sheet 

As can be readily seen the clinical decision rendered by the BFCC QIO is dependent upon the documentation within the last three days prior to discharge. The completeness and accuracy of this documentation demonstrating patient clinical stability guiding and reinforcing the attending physician’s decision to discharge the patient is paramount to the BFCC QIO’s rendering a favorable decision of appropriate discharge by the physician and the hospital.

Generally speaking, CDI’s efforts at documentation improvement are focused upon the early stages of admission in an attempt to secure the most clinically specific principal and secondary diagnoses. After the record is optimized through the query review and physician response process, the CDI specialists may not rereview the record since he/she has fulfilled the mission of clarifying diagnoses from the onset of admission.

Here lies the problem and major limitation with the current CDI process centering upon reimbursement. The opportunity to address the insufficiencies of documentation related to telling of a precise and contextually correct patient story that explicitly and clearly outlines the reason for admission, patient severity of illness at onset of admission including a vivid picture of clinical instability, patient care rendered including diagnostic workup and treatment, and patient response to the therapy and progress towards discharge and clinical stability of the patient at the time of discharge as evident in the last few days of care, is not best served by the current CDI processes.

Present-day fundamentally flawed processes miss the opportunity for CDI to positively affect the quality and completeness in communication of patient care spanning from initial ED presentation to H & P, progress notes, and discharge summary. The ideal CDI model assimilates and takes into account the notion that patient care is fluent versus today’s CDI static in time approach, frontloading chart review and basically overlooking the documentation and communication of care toward the back end.


Doing the Right Thing for the Patient—Getting Started

CDI must not lose sight of Doing the right thing for the patient moving forward. The industry can move in the right direction by recognizing that the record serves primarily as a communication tool for the patient, the physician, and all other relevant healthcare stakeholders. Effective communication of patient care for the entire stay by definition entails a holistic approach to documentation improvement consisting of insuring clear, concise, consistent and contextually correct documentation throughout the entire patient encounter. This requires an encompassing broad-based outlook of our assigned duties and responsibilities as CDI specialists.

We are not mere chart reviewers with expectations of diagnoses reporting; instead we are facilitators of communication of patient care, working closely in collaboration with physicians, case managers, utilization review/management staff, social workers, and quality control to provide the best care possible while moving the patient efficiently along the continuum and beyond. This continuum extends to post-acute care with a bent towards population health and preventive care, recognizing that hospitals will be rewarded for keeping patients healthy and insuring hospitalization when only medically necessary.

I submit to CDI professionals to take a stance against the status quo of repetitive transactional reactionary processes fixated upon reimbursement. We can achieve our potential for documentation excellence if we take action and address present limitations of CDI.

Only you can make a true difference in documentation improvement if and when you commit.


Program Note

Listen to Glenn Krauss report on this subject during this morning’s Talk Ten Tuesdays broadcast, 10-10:30 a.m. EST.

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