March 20, 2018

Why CDI Often Times Goes off the Rails

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Moving beyond CDI to optimize reimbursement requires returning to an optimal and sustainable level of achievable excellence.

 A well-guided, thought-out, directed mission is paramount to driving and ensuring success in any professional role – and this particularly holds true for the profession of clinical documentation improvement (CDI). In my travels as a consultant and in speaking with numerous CDI colleagues, I have become convinced that the major limiting factor in clinical documentation improvement effectiveness and outcomes is the targeted mission of the profession preventing optimal sustainable achievement of excellence.

With the rapid evolution in healthcare delivery models and emphasis on quality, value, cost-effective outcomes, patient centeredness, and healthcare prevention, all impacted by the accuracy and completeness of clinical documentation and derived data, the imperativeness of a thoughtful, well-designed, meaningful mission of CDI cannot be overemphasized.

 

Today’s CDI Mission

Today’s ingrained CDI mission is centered primarily around reimbursement, although the profession attempts to intertwine quality of care and patient safety into the equation. A closer look at overall operational processes, including frequent posts on LinkedIn as well as national association conferences and webinars, clearly reveals that reimbursement is the motivating force of the CDI industry.

This moving force in CDI has been established and continues to be perpetuated by CDI consulting companies using reimbursement as the underlying theme in their sales and marketing efforts directed toward chief financial officers. Resultingly, hospitals and health systems continue to embrace the current CDI model in anticipation of increased reimbursement, mistakenly under the pretense of “clinical documentation improvement.”

The term “clinical documentation improvement” obviously implies improvement in the quality and completeness of documentation, yet in today’s model there is virtually no improvement in the actual quality of and communication of patient care. Therein lies the problem with current thought processes and outcomes of CDI; they were never designed or intended to materially improve documentation with reasonable sustainability.

Whenever you focus upon outcomes, consisting of reimbursement with associated tasks and growing to include enhanced reimbursement, the processes established to achieve such outcomes have a strong tendency of overlooking actual long-lasting improvement in meaningful documentation. A quick review of industry-supported measures of effectiveness of CDI programs showcases tasks that lack correlation with true communication of patient care, as follows:

  • Number of charts reviewed per day

  • Number of queries generated per day

  • Response rate by physicians, including calculated agreement rate

  • Number of queries that increase reimbursement versus quality measures

  • CC/MCC capture rate

  • Number of secondary reviews conducted

  • DRG agreement rate between CDI specialists and coders

  • Case mix index increase

 These key performance indicators clearly are no indication of enhancement in documentation quality achieved through CDI processes; just examine the increasing number of clinical validation and medical necessity denials, not to mention DRG downcodes associated with insufficient and/or poor physician documentation. Often, diagnoses generated by the ongoing query process generate and continually contribute to exponentially increasing non-technical denials, attributable to inconsistent, imprecise, unclear, and/or contextually inaccurate clinical information, facts of the case, and clinical context of the patient encounter.

Just recently I identified a chart for which the physician copied and pasted the last progress note into the discharge summary, something one can emphatically agree does not represent documentation improvement and impairs quality of care reporting.  

 

The Real Mission of CDI: Creating a Vision that Inspires

The underlying theme of a well-crafted and closely followed mission of CDI recognizes the patient as the center of attention, and it focuses on documentation improvement and measured outcomes. Take a careful look at the following aspects of a suggested mission of clinical documentation improvement that speaks to the patient, first and foremost:

  • Achievement of complete, organized, and accurate medical record content documentation, reflecting the physician’s clinical judgment and medical decision-making.

  • CDI supports positive outcomes in patient care, quality, cost, resource consumption, fee-for-value, patient reimbursement, and revenue cycle processes.

  • CDI exists to improve actual processes of clinical documentation, with staff striving to achieve meaningful and lasting changes in physician behavioral patterns that optimally reflect communication of patient care.

By focusing on primary outcomes of reimbursement, we are overlooking the vitally critical component of true documentation improvement. Enhanced reimbursement should be thought of and treated as a byproduct of solid documentation reflective of medical necessity for inpatient care, continued hospitalization stays, and discharge stability. In short, appropriate resource consumption and utilization review/management processes under the Conditions of Participation, quality and efficiencies of care delivery, achieved outcomes, and accurate clinical validation of all assigned ICD-10 codes and DRG assignment should be the ultimate goal of the profession of CDI.

 

Is Your CDI Mission Ripe for Change?

I am adamant that the profession of CDI must arrive to the conclusion that the current mission, goals, and objectives must evolve to address the continually evolving requirements of documentation. Rather than relentlessly focusing upon clinical documentation as a means of affecting positive change in reimbursement, we must not forget the patient and the purpose of the medical record as a communication tool for patient care.

Clinical documentation serves as a vehicle to track a patient's condition and communicate the author's actions and thoughts to other members of the care team. The medical record is used by physicians to record their findings and actions, and as a vehicle to communicate with other physicians who might care for the patient in the future. I am calling on CDI leadership to reject the current model of CDI and embrace the notion of CDI incorporating the philosophy of true documentation improvement serving the patient, the physician, and all other relevant patient stakeholders.

Physicians are not a means to an end, nor should they be the targets of endless queries made in the name of the almighty dollar. I submit to you the idea that we must work with physicians as strong partners in securing sound and complete documentation that best reports quality-oriented patient care. In summary, effective communication of patient care delivers the byproduct of optimal reimbursement in a compliant and reasonable manner, thereby aligning with the revenue cycle.

 

Program Note:

Listen to Glenn Krauss report on this subject during this morning’s Talk Ten Tuesdays broadcast, 10-10:30 a.m. EST.


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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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