CDI programs are viewed by most physicians as hospital-led initiatives geared towards increasing reimbursement for the hospital.
The majority of clinical documentation improvement (CDI) programs fail to effectively engage physicians as willing participants in the push to accurately capture patient care provided through clear, concise, and contextually consistent reporting.
Clinical documentation serves to track a patient’s condition and communicate the author’s actions and thoughts to other members of the care team, per the Annals of Internal Medicine; Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper from the American College of Physicians. The CDI profession’s treatment of the medical record as a primary mechanism for capturing reimbursement prevents optimal achievement of success in documentation improvement, and even more importantly, detracts from the ability to fully engage physicians in learning about, focusing on, and incorporating elements of best practices in documentation into their daily practice of medicine.
My personal experiences in conversations with numerous physicians validates the notion that CDI programs are viewed by most physicians as hospital-led initiatives geared towards increasing reimbursement for the hospital at the expense of precious time responding to repetitive queries, day in and day out. There simply is little recognizable focus upon guiding the physician in taking steps to improve the quality, completeness, and efficiency of their clinical documentation.
Present CDI Efforts: Proof in the Pudding
The perceived standard principle of CDI is securing additional reimbursement for the hospital through repetitive chart review and recognition of additional diagnoses and/or clinical diagnostic specificity: it’s something of a Band-Aid approach to sustainable clinical documentation improvement, or alternatively, quite similar to the concept of a fix-a-flat can. The repair is only temporary, just like the process of continual queries on the hunt for funds for the hospital.
Allow me to share a paraphrased conversation with a CDI colleague that highlights why physicians have a tendency to resist a participatory style of engagement in regular CDI processes. My colleague mentioned in passing that a physician she works with on the professional side of documentation, coding, and billing arena copied her on an email in response to a CDI specialist’s query requesting clarification on the type of debridement performed on a patient. In fact, she received two emails from this surgeon on the same day displaying obvious reservation about responding to the query – likely due to a lack of understanding regarding the relevance of the queries.
This lack of response or reservation about responding clearly highlights the underlying deficiencies and shortcomings in most CDI programs; that is, physicians are not able to clearly see the value of complete and accurate clinical documentation. Instead it is viewed as an attempt to squeeze as much reimbursement out of every record as possible, at the expense of incorporating the physician’s perspective on the tangible value of documentation effectiveness.
Securing documentation of something like debridement is always challenging, and it still remains elusive as associated with the majority of CDI programs. The differentiation often hinges on “excisional” versus “non-excisional,” with advice and guidance provided by the Coding Clinic. My response to my colleague was “I wonder if the CDI specialist has invested the time in explaining the documentation requirements for debridement from the physician perspective, as many Medicare Administrative Contractors (MACs) requires specific documentation detail outlined in a Local Coverage Determination (LCD).”
The MAC in this instance is located in New England, and it does have an LCD for debridement services, available online here: (Debridement LCD). The LCD for Debridement Services (L33614) provides an overview of debridement, including definitions of the procedure, indications, limitations of coverage, documentation requirements, and utilization guidelines.
A CDI specialist equipping herself or himself with the core knowledge and familiarity of the definition of debridement, when the service is covered, what the indications are, and what the specific documentation requirements are can serve as a strong foundation for sharing actionable knowledge with the physician. As the healthcare industry moves away from fee-for-service and toward fee-for value, wherein the underlying premise is the practicing of cost-effective, patient-focused, quality-centered, efficient and effective care rises, it will drive the overall healthcare delivery model. As such, physicians must embrace the critical importance of delivering and reporting the right care at the right time for the right reason in the right venue with the right documentation – containing the right clinical judgement and medical decision-making, with the right plan of care and follow-up.
Debridement: Where and What Should the CDI Focus Be?
The most effective physician-engaging approach to addressing and consistently dealing with the quandary of type of debridement procedure performed is to create a holistic message to physicians in an informative manner regarding the standards of documentation for such services. Repeatedly querying for the same details, day in and day out, is an exercise in futility and inefficiency, something that haunts the CDI profession – with CDI consulting companies too often promoting the ill-conceived notion that more queries generated translates into more reimbursement. Instead, CDI should start a campaign to reduce the need for queries of debridement by sharing specific documentation requirements, starting low and going slow – like a physician starting a medical regimen for a newly diagnosed hypertensive patient. Key document provisions include but are not limited to:
- An operative note or procedure note for the debridement service. This note should describe the anatomical location treated, the instruments used, whether anesthesia was required, the type of tissue removed from the wound, the depth and area of the wound, and the immediate post-procedure care and follow-up instructions.
- Identification of the wound location, size, depth, and stage, either by description and/or a drawing or photograph.
- A description of the type(s) of tissue involvement, the severity of tissue destruction, presence of undermining or tunneling, necrosis, infection, or evidence of reduced circulation. If infection has developed, the patient’s response to this infection should be described.
- The patient’s comorbid medical and mental condition, and all health factors that may influence the patient’s ability to heal tissue, including but not limited to the following: mental status, mobility, infection, tissue oxygenation, chronic pressure, arterial insufficiency/small vessel ischemia, venous stasis, edema, type of dressing, and chronic illness such as diabetes mellitus, uremia, COPD, malnutrition, CHF, anemia, iron deficiency, and immune deficiency disorders.
Supportive Documentation Requirements
- Etiology and duration of wound
- Prior treatment by a physician, non-physician practitioner, nurse, and/or therapist
- Stage of wound
- Description of wound: length, width, depth, grid drawing and/or photographs
- Amount, frequency, color, odor, and type of exudate
- Evidence of infection, undermining, or tunneling
- Nutritional status
- Comorbidities (e.g., diabetes mellitus, peripheral vascular disease)
- Pressure support surfaces in use
- Patient’s functional level
- Skilled plan of treatment, including specific frequency, modalities, and procedures
- Type of debridement performed, including instrument used, to support the debridement code billed
- Changing plan of treatment based on clinical judgment of the patient’s response or lack of response to treatment
Clearly, there is ample opportunity for improvement in documentation of debridement procedures that we should and must achieve. A reasonable starting point is to consider developing a tip sheet or resource card for surgeons to follow in their documentation of debridement procedures, with inclusion of key elements of documentation necessary in the chart to tell the patient story in sufficient detail so as to allow any other physician to be able to review the note and clearly understand what was performed, why, and what the plans are for continued care. You also may wish to consider working with your physicians and informatics folks to create a template in the electronic health record (EHR) to sufficiently document the details of the debridement procedure, with inclusion of the clinical facts associated with the physician’s decision to perform the procedure. Sharing actionable pieces of information serving as the basis for promoting the merits of documentation to physicians creates an ideal basis for physicians to assimilate the facts, arrive at their own conclusions, and take the appropriate courses of action. In this instance, physicians likely will be more receptive to documenting the type of debridement procedure performed (along with the other accompanied information) when they realize the necessity for providing a complete picture of the patient. The old adage of WIFM – What’s In it For Me – is still hard at work in the physician community.
Looking at the Entire Picture
I want to leave you with a few thoughts that will serve as the basis for operationalizing effective principles of clinical documentation improvement into your regular practice of CDI. To this end, you will be taking the right steps in enhancing engagement of physicians in documentation improvement initiatives by creating a collaborative working relationship with them, helping them help their patients while also helping themselves in the accurate reporting of their practice of medicine.
First, reject the notion that the profession exists to secure diagnoses impacting reimbursement only for the hospital; this is counterproductive for impacting measurable, meaningful change in the effectiveness in communication of patient care. Think of our role as CDI specialists to help physicians perform what William Osler, the father of modern medicine, described as a mechanism for observing, recording, tabulating and communicating patient care.
Second, take it upon yourself to expand your depth and breadth of knowledge in CDI, including applying best principles and standards of clinical documentation in our chart reviews, acquiring the core knowledge and skill sets necessary to identify common documentation insufficiencies, and ensuring that we can collaborate with physicians to improve.
Thirdly, avoid being satisfied with the status quo and the complacency associated with current CDI processes of lobbing queries at physicians, thinking that this constitutes actual documentation improvement. And lastly, remain true to the role of a CDI specialist as an integral part of the practice of medicine, as opposed to treating it as a job. CDI is not an arena where one can ride the wave to retirement, doing the same thing every day without considering the necessity for continuous quality improvement. We must personify the value we bring to the table if we are to be committed to ongoing growth and development.