Expanding the Role and Framework of CDI

July 7, 2016

by Glenn Krauss, Regional Director of Enterprise Solutions, ZirMed

Clinical documentation improvement specialists play a vital role in the hospital revenue cycle world. When one refers to “CDI,” what in-arguably comes to mind is clarification of diagnosis, whether it be primary or secondary diagnosis, HACs or present on admission indicators. Our main goal is to ensure documentation of any and all clinically relevant diagnosis to the extent we can truly insure the record reflects and reports an accurate representation of patient severity of illness and risk of mortality in support of communication of patient care as well as ICD-10 code and MS-DRG assignment. Given the current business environment of healthcare with increased competitiveness from other hospitals and healthcare facilities—as well as the aggressiveness of third-party payers to question the medical necessity of delivered services and propensity to deny payment—how can clinical documentation improvement specialists more closely align and integrate our role with the goals and objectives of the hospital revenue cycle?

More pointedly: what can we do to effectively expand our present initiatives and better contribute to revenue integrity—delivering improved financial performance that stands the test of time?

Expanding the CDI Role!

As clinical documentation improvement specialists, we must recognize and be cognizant of the fact our CDI efforts constitute a role versus a task. CDI is much more than the reviewing of charts and leaving of queries for clinical specificity and clarification of clinically warranted additional diagnoses. Instead, we must recognize and champion our role in synergistically enhancing and improving the communication of patient care, thereby supporting all the healthcare constituencies dependent upon accurate and complete medical record documentation. Consider all the stakeholders – the scale is significant. Attending physicians, consultants, case managers, utilization review/management, social work, discharge planners, quality outcomes and safety staff, ancillary service providers, infectious disease specialists, risk department, compliance staff, physician advisors and post acute care providers including primary care physicians. Ask yourself whether we are truly improving clinical documentation from a perspective of accurate, complete and succinct communication of patient care reflective of patient acuity at the time of decision to hospitalize the patient? And: are we capturing the need for continued stay in the hospital, patient response to planned therapy, congruence of patient assessment to plan of initial and ongoing care, change in therapy and/or diagnosis through progression of hospital stay, establishment of medical necessity for admission, medical necessity for all diagnostic workup and therapeutic treatments, stability of the patient at discharge and an encompassing discharge summary incorporating the six required Joint Commission elements?

How do we make the leap to embracing the recognition and promotion of this complete and accurate level of documentation into our regular duties and responsibilities of chart review query process? A reasonable starting point is changing our mindset and focal point of review when we “open” a record for the first look. Review the Emergency Room record and History and Physical at the earliest feasible date and time as opposed to waiting 24 to 48 hours for the initial clinical workup to ensue. Don’t wait until “the dust settles.” The clinical context and content of admission, what is known and recorded at the time of decision to hospitalize the patient is key to effective establishment of medical necessity. Clinical facts of the case well executed and clearly explained in the ER and H & P are essential provisions of medical necessity, yet we devote very little time and effort in promoting and affecting positive change in physician behavior patterns of documentation in this recording. These clinical facts include recording of a patient’s chief complaint, accurate taking of inventory of history of present illness versus past illness relevant to the patient’s presenting signs and symptoms, and clinically relevant review of systems as well as past family social history. The accurate recording of the chief complaint and history of present illness is fundamental to establishment of medical necessity through a clear picture of the nature of presenting problem. In short, these elements are a close proxy for how sick and severe the patient was at time of presentation to the Emergency Room and at the time of admission to the hospital. The majority of medical necessity denials can be attributable to insufficient documentation of the patient’s severity of illness including signs and symptoms and nature of presenting problem. Always ask yourself whether the H & P describes and shows clearly why the patient is being admitted to the hospital.

If the answer is no, then you can unequivocally assume that all of our efforts at securing clinical specificity as well as additional diagnoses when clinically warranted by clinical indicators and treatment will not necessarily achieve a reasonable return on investment if outside reviewers question the validity of admission. Clinical content, context, and clear expression and recording of the clinical facts of the case are paramount to clinical documentation improvement. Simply put, CDI initiatives bear little return on investment in the delivery of quality of care if there is no payment for rendered services.

What is your program’s CDI ROI Quotient? This may be an ideal time to revisit and restructure the framework of your initiative to reach new heights and realize the full potential of CDI!

Contact us if you’d like to continue the dialogue around CDI improvements.

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