When CDI Fails: The Unrelenting Pursuit of Reimbursement

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Original story posted on: September 16, 2019

The CDI is more than diagnosis capture through the query process.

The Association for Clinical Documentation Improvement Specialists (ACDIS) recently released a paper titled Proactive CDI: Tackling the Problem of Physician Engagement, which featured six CDI leaders outlining their thoughts and ideas on facilitating physician engagement in CDI initiatives within their healthcare facilities.

In reading the article, on several separate occasions, I became convinced that the paper overlooked a tremendous opportunity to define physician engagement in the most direct favorable light and to guide fellow CDI ACDIS members toward various strategies to consider.

Allow me to share my experiences in my extended career in CDI, working hand in hand with physicians collaboratively to drive real improvement in clinical documentation.

Physician Engagement: The Real Meaning, Put in Proper Perspective

I set out to see what I could find on physician engagement on the Internet that caught my eye and emulated my thought processes in defining physician engagement. A quick search came up with this definition, which correlates with my philosophy of physician engagement that I consistently strive for:

  • Physician engagement is a strategy used to create stable relationships between physicians and healthcare organizations. A higher rate of physician engagement correlates with enhanced patient care, lower costs, greater efficiency, and improved patient safety – as well as higher physician satisfaction and retention. Properly executed physician engagement strategies are a critical success factor for navigating the integrated nature of delivery system transformation, enabling better quality care across the board (Eviarant- Physician Engagement)

Let’s take a deep dive into physician engagement with respect to CDI initiatives. A major challenge for CDI programs is fully engaging all physicians in the power of effective communication of patient care through solid practices of clinical documentation. Medical record charting, while certainly considered to be a large administrative burden by most physicians, does not necessarily have to be that way. There are efficiencies to be achieved in medical record charting if physicians become familiar with strategies of documentation that cut to the chase, with the inclusion of key elements to best tell the patient story with an accurate reflection of the physician's clinical judgment.

A strategy to engage physicians in implementing best-practice standards of clinical documentation with precious administrative time-saving tendencies serves as the underlying fundamental basis for CDI operational processes. Physicians’ primary interest is in serving their patients’ healthcare needs. An engaged physician takes to heart the strong relationship between quality documentation and quality medicine, with the strong association between complete and accurate documentation and the achievement of fully informed, coordinated, quality/outcome-based, cost-effective and patient-centered care.

Unfortunately, the CDI industry as a whole has latched on to the notion that CDI is primarily about diagnosis capture through the query process. Following the vision of CDI as an initiative to enhance reimbursement, devoid of any significant effort to actually improve the quality of physician documentation beyond diagnosis capture, the profession attempts to backfill physician engagement with processes such as creation of templates, computer-assisted physician documentation (i.e., diagnosis capture), the development of tip sheets, reference cards, and newsletters, and short presentations at physician department meetings.

What we are really accomplishing in this manner is increasing physician administrative burden through the query process and other activities, in the unrelenting pursuit of reimbursement that often fails to materialize – a fact attributable to second-guessing activities on the part of the third-party payors. Just witness the increasing volume of medical necessity and clinical validation denials, as well as DRG downgrades.

What Is Strikingly Missing from This Equation?

A quick read of the ACDIS paper highlights a key point that is strikingly missing but should serve as the premise of any CDI initiative. Notice there is no mention of the patient in this document; the thrust of the article is on physician engagement in the documentation of diagnoses that either enhances reimbursement or improves quality scores for the hospital.

Now, don’t get me wrong, I fully embrace optimal reimbursement and quality scores for any facility, provided that the supportive clinical documentation appears in the record. In light of the growing volume of denials hospitals are facing, one can argue that this degree of documentation is not yet widespread. The CDI profession has overlooked the patient benefactor in its quest to “improve the integrity” of the documentation.

A very timely article that appeared in the Sept. 12 edition of Modern Healthcare, titled Price Hikes, Upcoding Drive Massachusetts Inpatient Spending, drives home the very notion of CDI being primarily focused upon artificial improvement in documentation and increasing reimbursement, which do not necessarily equate to the patient’s true clinical acuity. The pieces below from the article sum it up nicely:

  • Commercial inpatient spending across the Massachusetts commonwealth grew 10.7 percent from 2013 to 2018, while volume decreased by 12.8 percent, according to the commission. That was primarily due to higher prices and patient acuity, although the HPC revealed that patients may have not actually been sicker.
  • The average commercially insured patient risk score surged 11.3 percent from 2013 to 2017, which is equivalent to an additional 413,000 patients with diabetes or 888,000 individuals with cerebral palsy. Theoretically, intensive care unit and cardiac care unit volumes, as well as the length of stay, should increase, but that wasn't the case, HPC data shows.
  • As the coding severity for chronic obstructive pulmonary disease increased by 20 percent, the ICU and CCU volumes declined by 7 percent and length of stay remained flat, suggesting that hospitals are maximizing coding rather than treating sicker patients.
  • "This is a known phenomenon," said David Auerbach, senior director of research and cost trends at the commission. "There are industries and consultants who have formed to take advantage of these higher payments and higher severity levels."

The question that sticks in my mind is to what extent did CDI efforts aimed at improving the “integrity” of the documentation contribute to this continuing trend of increasing inpatient hospitalization expenditures without a concomitant increase in real patient clinical acuity. The article raises another important concerning point related to the accuracy of downstream data used in the monitoring of care for a wide variety of applications: “it could also skew data. To the extent that risk scores reflect coding efforts rather than true patient acuity, risk-adjusted performance metrics like readmission rates, health-status adjusted total medical expenditures, mortality, or other quality measures are misleading, the commission said.”

Moving in the Right Direction

True physician engagement through proactive CDI processes is predicated upon partnering with physicians, physician advisors, and other stakeholders such as case managers, utilization review, and other revenue cycle professionals on behalf of the patient, the physician, the hospital, and the healthcare system. Accurate physician documentation is the fuel for patient care, with all aspects of healthcare delivery deeply dependent upon this documentation.

Designing CDI programs with the right mission that incorporates a highly regarded vision of truly working with physicians as collaborators ineffective communication of patient care constitutes the first step in the real engagement of the physician. Today’s ongoing transition to a value-based healthcare delivery model places an emphasis on the physician focusing upon the practice of medicine that incorporates the right care at the right time in the right setting with the right resources with the right clinical judgment and medical decision-making supported by the right clinical documentation.

Positioning ourselves as facilitators in documentation excellence through best practices of clinical documentation is the secret sauce that ultimately engages physicians. Software, templates, tip sheets, one-on-one education of physicians on documentation of diagnoses, to name just a few areas, is no substitute for physician engagement in effective clinical documentation of patient care for the mutual benefit of all healthcare stakeholders, including the patient. Quality and completeness of documentation are really what matters.

Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM

Glenn Krauss is well-recognized and respected subject matter expert in the revenue cycle with a specialized emphasis and focus upon collaborating and working closely with physicians in promoting, advocating for, educating and achieving sustainable improvement in clinical documentation that accurately reflects and reports the communication of fully informed coordinated patient care. His experiences include working with a wide variety of healthcare systems spanning the entire spectrum ranging from critical access hospitals, community hospitals, Federal Qualified Healthcare Centers to large academic medical centers and fully integrated healthcare systems. Glenn is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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