CDI: Is Your Toolkit Well Stocked?

Hospital services must positively contribute to the revenue cycle and clinical documentation integrity initiatives.

A recent outlook report released by Moody’s Investors Services spells continued ongoing financial challenges for non-profit hospitals next year. (Moody’s Survey)

The firm downgrade the sector from its current stable status to negative for 2018, attributable to a wide variety of interwoven factors including higher labor costs, lower revenue growth as more services are moving to the lower margin outpatient arena and the need to invest and upgrade current technology. Couple this with lower reimbursement from third party payers and a greater proportion of patient mix consisting of Medicare and Medicaid that traditionally do not cover the cost of care and you have a perfect storm for a tough economic climate.

So, you are probably asking yourself what does this have to do with clinical documentation integrity (CDI) and the revenue cycle? Plenty!

According to a Black Book survey of revenue cycle and coding management professionals from April 2017 to September 2017, 87 percent of hospital financial officers claim that the biggest motivators for adopting additional situations are to provide improvements in case-mix, resulting in increased revenues and the best possible utilization of high value clinical documentation improvement specialist. (Black Book Survey)

While I am philosophically at odds with chief financial officers (CFOs) treating CDI programs as cash cows or winning lottery tickets, the fact of the matter is all hospital services must positively contribute in some form or fashion to the revenue cycle and clinical documentation integrity initiatives are no different. A byproduct of an effective clinical documentation improvement program is solid reimbursement clearly supported by sustainable sound principles of documentation, emphasizing the necessity for clear, concise, contextually consistent clinical documentation.

Unfortunately, CFOs have been conditioned to equate CDI as a simple easy fix to insufficient documentation that prevents optimal assignment of ICD-10 cases, resulting in the “leaving of dollars” on the table in common CFO lingo. The adage of “if it sounds too good to be true, then it probably is not true” applies here. Taking the easy way out almost always leads to achievement of subpar performance and CDI is certainly no exception. Focusing upon reimbursement as the primary manta of CDI detracts from achieving full potential achievement of successes in CDI that closely align and integrate with the revenue cycle.

CDI Has Caught a Cold….and Will Never Recover

CDI programs can make a generally positive contribution to the revenue cycle through recognition of its capability and capacity to generate long-term sustainable improvement in the quality and effectiveness of physician documentation. Contrast this with the quick fix transactional repetitive retrospective approach of CDI queries, considered simply a Band-Aid approach to documentation improvement that sorely lacks the real-time engagement of physicians as willing participants. Why exactly has the CDI profession not graduated from and migrated away from the traditional query process, substituting for a more robust process that engages physicians in wanting to learn more about best practice standards of documentation, becoming more proficient in and integrating these standards into their daily practice of medicine? The answer ultimately lies in the design, organization, implementation and expectation of CDI programs in the first place.

Effecting positive behavioral pattern changes of physician documentation is not a realistic expectation of clinical documentation improvement programs; instead generating additional revenue through diagnosis capture is the number one priority in most not all programs, acknowledging that there are a minority of programs that exemplify what CDI initiatives stand for, complete and accurate communication of fully informed coordinated care. CDI programs with consulting companies at the forefront perpetuate the notion of an easy fix to insufficient and poor documentation by continuing to promote queries as synonymous with revenue generation.

What can be further from the truth rooted in fallacies and misnomers. Development of proactive processes to documentation improvement embracing and facilitating a proactive approach to improving documentation serves as a natural starting point in realigning and reintegrating CDI with the revenue cycle while achieving meaningful measurable improvement in clinical documentation.

What’s Missing- A Well-Stocked Toolkit

Today’s standard operating procedure for CDI is to equip CDI specialists with core knowledge, skill sets and wherewithal to review concurrent inpatient cases, identify and recognize opportunities for clinical clarification of diagnoses and follow through with written or verbal queries. The missing critical component to this madness of CDI is a CDI specialist lacking ready access to a well-stocked toolkit. What are these missing tools necessary to be a fully proficient effective professional in documentation improvement? A toolkit must contain a litany of specialized tools comprised of skill sets easily accessible to the CDI specialists (CDISs), allowing the individual to review the record, recognize and identify poor and insufficient documentation through the eyes of a diagnostic craftsperson, and develop and implement the best course of action working collaboratively with the physician to address any documentation shortfalls. The CDI toolkit includes CDI’s enhanced depth and breadth of knowledge of what constitutes sound documentation, with a keen eye to practical application and recognition of documentation ripe for improvement in conciseness, consistency, clarity and logical flow of recorded patient information.

A professional CDIS possesses the skill sets and confidence to address poor and insufficient documentation beyond diagnoses capture, insuring the integrity and completeness of the medical record from time of emergency department (ED) presentation, admission to the hospital, ongoing response to treatment reported in the progress note until discharge and the discharge summary.

One always inquisitively asks what are these skill sets. For starters, CDISs must fully understand the essential components of a history and physical (H&P) that actually describe, show and tell the patient story and depicts the patient’s severity of illness and acuity, clearly outlines the physician’s clinical impression including succinctly includes clinical rationale and thought processes and a clear-cut picture of what the plan of care is and what the physician is going to do with the results of workup and guidance of potential plan of care that may be warranted.

CDI should recognize and treat progress notes as more than strictly a repository for diagnoses, progress notes are not a billing document. Instead progress notes represent an account of the patient’s progress and response to treatment including evidence of clinical stability, i.e., is the patient slowly improving, worsening or staying about the same. The website UF 3rd year Medicine Clerkship serves as an excellent resource for progress note content, promoting and advocating for Larry Weed’s SOAP note format as follows (progress notes):

• S- This is where you record the information that patient tells you about how they did overnight
• O- This is the focused physical exam findings and lab, radiology, and other study results that are new since the last note.
• A- This is where you state the working diagnosis and comment on whether it is improving, worsening, or the same.
• P- This is where you list the plan, tests, and/or therapies.

We must avoid the temptation to think of the progress note as merely a hunting ground for diagnoses, getting what we need documented in the progress notes and running to the next case and engage once again in the hunting process, repeating this process and referring to it as “clinical documentation improvement.”

Recently, I received feedback from a post on LinkedIn that this scale of documentation improvement is not within our scope of practice, should be taught in medical school and reinforced by other clinicians with physicians held accountable for fulfilling their obligation to their patients and the practice of medicine with consistent, accurate and complete documentation.

Effective clinical documentation is unlike ordering a pizza at a pizzeria where you have the privilege of choosing from many toppings to accompany the cheese. Effective clinical documentation for sake of patient care is not an option in the scheme of healthcare. If the profession is going to successfully transition to meet the myriad uses of clinical documentation beyond reimbursement associated with value based payment methodologies, we must acknowledge and come to terms that present-day efforts at clinical documentation improvement no longer suffice.

Our present-day manta for CDI must incorporate the notion that our goals and objectives of clinical documentation improvement is to enhance the communication of patient care which includes clinical information, clinical facts of the case and clinical context culminating in an encompassing assessment- all relevant clinical diagnoses with appropriate specificity with congruent plan of care. In short CDI must subscribe to the philosophy of securing adequate documentation depicting the provisions of the right care at the right time for the right reason in the right venue with the right clinical judgement and medical decision making with the right appropriate plan of care. Documentation is the common theme in meeting these objectives in healthcare. We must work in collaboration with case management and utilization review/management versus working in silos to affect positive change in documentation patterns.

Putting This in Proper Perspective

If CDISs individually and collectively accept our role and responsibility to actually achieve meaningful measurable improvement in clinical documentation as opposed to chasing diagnoses, we will certainly make inroads in better aligning and integrating with the revenue cycle. Of note is the Centers for Medicare & Medicaid Services (CMS) Improper Payment Rate for fiscal year (FY) 2017 was recently released, showing a drastic improvement in the payment error rate from FY 2016, dropping from 11.0 percent in 2016 to 9.5 percent in 2017, representing a $4.9 billion decrease in improper payments.

The majority of Medicare fee for service (FFS) improper payments are due to documentation errors where CMS could not determine whether the billed items or services were actually provided, were billed at the appropriate level, and/or were medically necessary. Insufficient documentation accounted for 64 percent of improper payments. (CMS improper payment rate)

Let’s take a hard look at our current CDI initiatives and truly consider positioning ourselves as dedicated and committed professionals championing the cause of clinical documentation improvement, simultaneously addressing the monumental economic challenges our hospitals continually face in providing quality focused patient centered care while remaining financially solvent.

Please offer this some thought and consideration.

Program Note: Listen to Glenn Krauss this morning on Talk Ten Tuesdays, 10-10:30 a.m. EST.