The CDI profession has failed to effectively articulate its value in the revenue cycle.
An American Hospital Association (AHA) report released June 30 finds that the financial strain facing hospitals and health systems due to COVID-19 will continue through at least the end of 2020, with total losses expected to be at least $323 billion for the calendar year.
Working in the healthcare industry, I have seen colleagues and friends in the sector being laid off or furloughed, attributable to financial challenges associated with significant revenue shortfalls from COVID-19 impacting overall operations. The ongoing public health emergency (PHE) will undoubtedly continue to pose issues, with hospitals continuing to resort to mass furloughs, early retirements, and layoffs; labor makes up nearly 60 percent of the healthcare dollar. Physicians are not exempted from these furloughs and layoffs, which are occurring as a direct result in decreasing volumes of elective surgery, emergency room patient encounters, and overall patients, who may avoid the hospital setting out of fear of COVID-19. Even clinical documentation integrity (CDI) professionals with long careers in CDI are being furloughed and laid off, with one health system just announcing a cut of 30 such professionals.
Why is CDI Impacted?
Several of my seasoned CDI colleagues have been furloughed for the last three months, while some of my colleagues have had their hours reduced to 32 in a week, putting undue strain on themselves and their families. These furloughs and layoffs beckon the question of why CDI is being negatively impacted by the COVID-19 PHE, if CDI activities are essential in the scheme of physician documentation integrity and its attainment.
There exists a simple explanation for this negative impact: the profession has failed to effectively articulate its value in the revenue cycle. The CDI profession, by focusing upon the query process as the hallmark of CDI, has branded task-based activities as the fundamentals of clinical documentation integrity.
Current CDI processes are predicated upon reactive, transactional, repetitive activities, perpetuated by task-based key performance indicators (KPIs) that purport to drive optimal hospital reimbursement. Historically, over time, physician queries do not alter overall physician behavioral patterns of documentation of diagnoses, as evidenced from the fact that most facilities are still querying for type and acuity of heart failure consistently – this despite the fact that ICD-10 codes for specificity of heart failure have been in existence for some time now. Consider other common diagnoses that rise to the top of query volumes, including encephalopathy, acute renal failure, acute respiratory failure, type of chronic kidney disease, etc. When record volumes decrease, dictating fewer chart reviews for CDI, it stands to reason that CDI specialists will be furloughed or laid off. Compare the current value proposition predicament CDI has created through their overreliance upon task-based activities to that of the case management and utilization review profession, wherein each individual plays a vital role in the overall healthcare delivery model. The CDI profession can learn much from studying and understanding the dynamics of these specialties by shadowing these individuals for a day. This will certainly be an eye opener for the profession.
CDI Stepping Up Its Game
The CDI profession must step its game, and recognize the opportunity to transform itself into a powerful force in achieving clinical documentation excellence through well thought-out and designed processes that drive revenue preservation, rather than revenue optimization; there is a distinct difference between the two, with the primary goal of CDI incorporating revenue “preservation” deep into our chart review processes and mission. The concept of revenue preservation requires attainment of complete and accurate physician documentation that CDI must achieve through formation of a true partnership with physicians that is sustainable over time.
Physicians must not be simply thought of and treated as throughput for complication and comorbidity (CC) and major CC (CC/MCC) capture using the query process, repetitively lodging burdening queries day in and day out with the goal of meeting arbitrarily defined KPIs. These KPIs inarguably bear no resemblance to nor support revenue preservation, mainly due to the fact that diagnoses captured without solid physician documentation that best reports the patient’s story, accompanied and supported by the clinical facts, information, and context, leaves the door wide open for medical necessity and clinical validation denials – as well as level-of-care and DRG downgrades. Because present CDI processes were never designed nor intended to achieve measurable, long-lasting improvement and integrity in physician documentation, it is not surprising that CDI activities do not address revenue preservation, through a lack of a preemptive denials avoidance approach.
In many ways, CDI is a cost center, as opposed to a revenue generator, in light of the fact that the profession overlooks the opportunity to share best practices or standards and principles of documentation that adequately communicate patient care, including the need for hospital level of care with inpatient status, as warranted and supported by the clinical facts. This is proven out in the Centers for Medicare & Medicaid Services (CMS) 2019 Comprehensive Error Rate Testing (CERT) Contractor Improper Payment Report that identified within the fee-for-service inpatient Part A MS-DRG improper payment category that nearly 80 percent of improper payments were due to medical necessity and insufficient documentation. Logically speaking, medical necessity and insufficient documentation are one and the same, since more than 50 percent of medical necessity denials can be avoided with more effective physician documentation that is information-rich versus data-rich, with actionable information the reader can practically apply in the establishment of medical necessity.
A Financial Savior: Commitment to Change
Until the CDI profession steps up to the plate and invests the time, energy, and commitment to update current CDI processes tailored to short-term gain at the expense of long-term enhancement of the completeness of medical record, CDI will continue to be recognized and treated as a temporary fix. This treats the CDI profession as basically a task-based entity, dependent upon hospital patient volume, paralleling a manufacturing environment, whereby if demand is curtailed, manufacturing is curtailed.
A reasonable starting point for the long journey to CDI relevance is to raise the bar for skill sets that equip the profession to become highly proficient in working with physicians as constituents in sharing best-practice standards of documentation. The CDI profession must recognize the medical record as a communication tool versus a reimbursement tool, aligning efforts at achieving clinical documentation excellence that at a minimum, preserves revenue that hospital is entitled to be reimbursed for, based upon care provided.
Without medical necessity demonstrated through an accurate picture describing the patient’s severity of illness, CDI does not matter; it is simply irrelevant. Today more than ever, revenue preservation is paramount to hospitals’ financial survival, with the stressors posed by the COVID-19 public health emergency. It’s time for CDI to step up its game, as doing the same thing and expecting different results is a lesson in futility. Generating more queries in the hopes of revenue that often does not materialize is not paramount to revenue preservation. Let us master revenue preservation first through real clinical documentation integrity as the foundation. Clinical documentation integrity, supportive of net patient revenue, with alleviation of the risk of financial recoupment, can be provided if the profession rejects the notion that queries are synonymous with CDI.