Each patient’s story should be told in the official record.

The clinical documentation integrity (CDI) profession has only scratched the surface of instilling positive change in patterns of physician documentation and communication of patient care. There exists a myriad of opportunities for CDI specialists to capitalize upon and truly improve the quality and effectiveness of clinical documentation throughout the record, engaging in a holistic approach versus a narrowly defined approach centering on diagnosis capture.

Limited Scope with Limited Benefit

Regardless of industry and job duties and responsibilities, a limited focus in one’s chosen or designated role generally produces limited benefit, and CDI is certainly not an exception. This week the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) and the United States Attorney’s Office for the District of Arizona announced a settlement with Banner Health, which will be paying over $18 million to settle false claims allegations related to Medicare billings for inpatient services. Specifically, it was alleged that 12 of Banner’s hospitals in Arizona and Colorado knowingly submitted false claims to Medicare by admitting patients who could have been treated on a less costly outpatient basis(Banner Health Settlement).

How does CDI fit into the equation here, and could Banner have mitigated the magnitude of allegations of inappropriate hospital admissions in these instances?

Today’s present model of CDI is predicated upon a narrowly defined scope of practice, mostly consisting of diagnosis capture. While there are limited variations to the current model, the primary goal of CDI centers upon reimbursement – to the exclusion of numerous invaluable contributions CDI can make to the overall healthcare delivery process.

Let’s start with pointing out where CDI can expand its vision, mission, and goals in support of achieving optimal documentation. The medical record serves first and foremost as a communication tool for patient care, allowing the physician to show the entire patient story.

Understanding and accurately reflecting the patient story drives consistently accurate diagnostic conclusions, and it illustrates the need for patient care, whether in the office or hospital. In the inpatient setting, the CDI review process emphasizes the review of emergency department accounts of care, the history and physical, as well as all available diagnostic workup and treatment as an integral part of identifying opportunities for diagnosis clarification and specification.

The query process does serve a valid purpose in solidifying the patient story with the culmination of documented diagnoses currently under active management that occasioned and/or contributed to the hospitalization. Just the same, we are overlooking a critical part in the communication of patient care that, if executed properly and effectively, will be of material benefit to the patient, the physician, and all healthcare stakeholders involved directly or indirectly with patient care, as well as the overall revenue cycle.


Capture of the Patient Story: The Missing Link

Telling each patient’s story in a manner that best communicates the patient’s care does not require more documentation, just more effective and complete documentation – without the unnecessary distractions that create issues with patient situational awareness perpetuated by the electronic health record. With physician documentation, more is not better; better is better.

CDI specialists can meaningfully assist physicians in the documentation of the true patient story, but first they must become more proficient as it pertains to the process. Each patient represents a story, and the CDI professional must recognize and treat the medical record as a tool to tell it, rather than a tool that facilitates the generation of clinical queries in pursuit of reimbursement. An article titled “To Be a Great Physician, You Must Understand the Whole Story” makes several key points worthy of discussion, highlighting how my facility’s current CDI team assimilates and incorporates into their daily chart review their various duties and responsibilities (Being a Great Physician):

  • Great physicians differ from good physicians because they understand the entire story. Only when physicians understand the complete story do they make consistent diagnoses.
  • Again, remember, each patient represents a story. That story includes their disease, any new problems, their social situation, and their social beliefs.
  • The story includes making the correct diagnosis or diagnoses. The story must describe the patient’s context. Who is this patient? What are the patient’s goals?

The crux of clinical documentation is that it must embrace the notion that the record must adequately tell the patient story. An effective patient story requires that the documenting physician possess a keen understanding of the patient. This is where clinical documentation improvement specialists can realize notable improvement in the documentation and communication of patient care.

Obviously, CDI is not in the business of the practice of medicine; just the same, the profession can facilitate the physician’s capture of the business of medicine through complete understanding and telling of the patient story. How this is best accomplished is clearly articulated in the same article referenced above as follows:

  • How do physicians understand each patient’s story? Physicians must develop excellent communication skills and gather the history in appropriate depth. Physicians must perform a targeted physical examination based on the historical clues. Physicians must order the correct diagnostic test and interpret them in the context of the history and physical exam. Once physicians collect the appropriate data, they then should construct that patient’s story.

A Sound and Reasonable Starting Point

A sound and reasonable starting point for approaching clinical documentation improvement in the strict sense of the term is for CDI to focus upon the patient story being told and documented clearly and completely. Proactivity in affecting positive change in documentation effectiveness is far superior than today’s reactive, repetitive, transactional approach to documentation improvement. The first step in the CDI chart review process is to ensure the physician’s understanding of the patient story. This is even before the CDI specialist can consider initiating a clinical query to clarify a diagnosis or diagnoses. Clinical information and context are paramount to accurately depicting the patient’s story, including severity of illness, presenting signs and symptoms, chief complaint, history, assessment, and plan of care.

These encompassing elements are fundamental to the physician outlining what is known at the time of decision to hospitalize the patient. Under Medicare’s two-midnight rule, factors to be considered in the physician’s reasonable expectation of the patient requiring two midnights in the hospital are predicated on documentation of the patient’s severity of illness/signs and symptoms, clinically relevant co-morbidities, current medical needs, and the risk of an adverse event occurring during the time for which hospitalization is considered. The reasonableness of the inpatient admission for purposes of Part A payment is based on the information known to the physician at the time of admission. An expectation for sufficient documentation is rooted in good medical practice.

Logically speaking, CDI as a profession must update its vision, goals, and objectives in chart reviews, to include facilitating the physician’s communication of understanding of each patient’s story.

An effective strategy to accomplish this involves enlisting the support of our physician advisors in advancing the objectives of clinical documentation improvement. Our role in documentation improvement is best served by an unwavering commitment to ensuring the right care at the right time for the right reason in the right venue with the right clinical judgement and medical decision-making – to include the right clinical thought processes and plan of care with the right patient story, well-articulated and documented consistently within the record.

Stay tuned for a follow-up article, in which I will compare solid and complete documentation versus insufficient documentation from real case studies CDI specialists reviewed that were subsequently denied for inpatient medical necessity.

The CDI profession is highly capable of engaging physicians in a participatory approach to becoming proficient in best practice standards and principles of clinical documentation if we commit to this level of achievement.

We can certainly accomplish real change in documentation integrity;  I am seeing it at our facility. It starts with an open mind and determination to succeed.


Program Note

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

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