With unrelenting focus upon reimbursement within too many CDI programs, the opportunity to effectively improve the integrity of the medical record and its patient story is overlooked and foregone.
The majority of clinical documentation integrity (CDI) programs are mislabeled in their present format.
“Integrity” is defined as the quality or state of being complete or undivided, per Merriam-Webster. A few years back, the association representing the CDI specialist community elected to replace the “improvement” part of the title to “integrity,” meaning such workers are now referred to as clinical documentation improvement specialists (CDISs). The other association representing such workers followed suit, and changed the name to reflect “integrity.”
Why the name change? Well, the rationale included the thought that “integrity” better represents the mission of the profession: to enhance the integrity of the medical record.
Unfortunately, the CDI profession is not living up to that goal, missing the mark in achieving clinical documentation integrity within the record. I will touch on the reasoning for my sentiment on present-day processes of CDI that in too many instances unwittingly generate more costly, self-inflicted payer denials.
Reimbursement versus Integrity
The medical record serves first and foremost as a communication tool for physicians to record their findings, observations, thoughts, and clinical management of the patient, with capture of the physician’s clinical judgment and medical decision-making. In the words of an attorney, from a medical-legal perspective, the following describes the purpose of the medical record:
- To provide a complete and accurate description of the patient’s medical history. This includes medical conditions, diagnoses, the care and treatment provided, and results of such treatments. A well-documented medical record reflects all clinically relevant aspects of the patient’s health and serves as an effective communication vehicle. (Medical Record Documentation)
Let’s look at current CDI processes that focus primarily upon outcomes of reimbursement through complication and comorbidity/major complication and comorbidity (CC/MCC) capture and case mix index (CMI), facilitated by the query process. Whenever an intent of any initiative is revenue-driven, without concomitant focus upon improving actual processes related to the endpoint, the achieved outcomes are generally either short-lived, less than stellar, or detrimental in nature (or a combination of the three). An analogy is the response to a flat tire. There is either a spare tire, a “fix-a-flat” kit, or the car is equipped with “run-flat” tires. In either case, the fix is designed to be temporary in nature, with the driver required to repair the tire in question or purchase a new tire.
Now, let’s take a hard look at present-day CDI processes, involving the generation of queries to physicians for the purposes of solidifying secondary (i.e., CC/MCCs) or principal diagnoses that directly impact reimbursement. Additional topics commonly queried relate to Hierarchical Condition Categories (HCCs), core measures, patient safety indicators, and present-on-admission indicators, to name just a few. The point here is that too often, the effort and attention of the CDISs is placed upon task-based activities measured by key performance indicators (KPIs) that promote reimbursement outcomes. Present KPIs utilized to measure overall CDI performance include but are not limited to the number of charts reviewed, number of queries left, query response rate, physician query agreement rate, CC/MCC capture rate, CMI increase, etc.
While I fully support hospitals and physicians being reimbursed optimally for services provided, this short-term solution consisting of the query process must be recognized as a temporary fix. Queries produce short-term gain at the expense of sustainable long-term performance achievement of complete and accurate physician documentation, all the time, every time! By virtue of this unrelenting focus upon reimbursement within too many CDI programs, the opportunity to effectively improve the integrity of the medical record and its patient story is overlooked and foregone. The medical record as a multidisciplinary communication tool is what the CDI profession must recognize as the fundamental basis for their mission. In its present format, the CDI profession does not lend itself to “integrity.” A more appropriate descriptive title for CDI would be a “reimbursement improvement program.” At the end of the day, in too many programs there is very little improvement or integrity achieved within the medical record, aside from enhanced capture of diagnoses potentially impacting reimbursement.
Measured CC/MCC capture rate and CMI are figures that do not necessarily translate into real net patient revenue. Just because a claim is coded and billed with a particular MS-DRG or APR-DRG does not mean the payor will pay the claim as coded and billed. Payors operate under the guise that “it is not so just because the physician said it is so,” when it comes to physician documentation of diagnoses that are confirmed by a query. Payers are becoming more aggressive in their denials for clinical validation and DRG downgrades, and while a good number may be egregious in nature, solid, complete physician documentation that goes well beyond simple clinical validation is paramount to alleviating these costly denials – or increasing the ability to rehabilitate these same charts, if claims are denied by the payor. Clinical data validation means checking clinical data for correctness and completeness, that the diagnosis being queried (or the diagnosis already documented by the physician) is clearly supported by the diagnostic information within the medical record.
This is where a true CDI professional can shine, if one embraces the concept of “holistic chart review.” A reimbursement specialist pays particular attention to linking the diagnosis to clinical findings and results documented within the record. A true CDI professional recognizes both subtle as well as clear-cut physician documentation that will likely be a contributing or directly causative factor in a payor denial for medical necessity or clinical validation of a level of care (or a DRG downgrade). “Reimbursement integrity program specialists” are keen to capture diagnoses and reimbursement, while a bona fide clinical documentation integrity specialist understands and subscribes to the philosophy of treating the medical record as a multidisciplinary communication tool, recognizing the unwavering commitment to patients, physicians, and all other healthcare stakeholders involved in the care of each patient. The medical record as a communication tool requires a wide-eyed lens team approach to processes that affect positive change in overall physician behavioral patterns of documentation. Diagnosis reporting is just one small but critically important aspect of physician documentation. Improving the physician’s telling of the patient story, and the need for hospital level of care, continued hospitalization, clinical progress of the patient, readiness for discharge to post-acute care, and a sufficient discharge summary that meets Joint Commission requirements, at a minimum, is within the scope of the CDISs employing a team approach.
Making the Transition – Clinical Documentation Integrity Specialists
Hospitals and health systems are continuing to experience undue, long-lasting financial strain as part of the aftereffects of the COVID pandemic. Hospitals and health systems must strengthen all processes that support a high-performing revenue cycle, with collection of sustainable net patient revenue. Fundamental to patient care and the revenue cycle is quality-focused and complete physician documentation closely approximating the care provided with establishment of medical necessity.
The CDI profession must transform present-day operational processes to incorporate elements that achieve meaningful, measurable, long-lasting physician documentation improvement and integrity. Only the physician can move the needle on clinical documentation excellence. With the CDI profession becoming the change agent to clinical documentation integrity, working with physician advisors, physicians themselves, case management, utilization review/management, and other healthcare stakeholders, monumental strides can be accomplished in the overall quality and effectiveness of the medical record as a communication tool. This communication tool will best serve the patient and all involved directly and indirectly in patient care.
A byproduct is proactive denials avoidance documentation that is resilient to second-guessing by payers, resulting in financial recoupment. The time for CDI transformation is now.