by Glenn Krauss, Regional Director of Enterprise Solutions, ZirMed
National ACDIS CDI week is an ideal time to reflect on the accomplishments and trajectory of our profession. It’s also a fitting opportunity to formulate a strategy to continue our development and expand our ability to be a driving force in the transition to the fee-for-value model. Continuous quality improvement is the foundation for success in any business—and the business of CDI is certainly no different. We must not rest on our laurels or lose sight of where the marketplace is heading in the field of healthcare.
Continuous quality improvement can be defined in myriad ways; in the case of CDI, continuous quality improvement incorporates a change in mindset as the fundamentals and structure of chart review performance. Proactivity is the name of the game as the marketplace shifts from volume-based fee-for-service to value-based healthcare delivery models.
Delivering value-based care requires a strong correlation between outcomes, costs and measured value, whether direct or indirect. A key component and strong indication of “value” in the inpatient hospital setting is medical necessity – namely, did the patient require a hospital level of care that necessitated an inpatient admission? Traditionally, medical necessity was thought to be the concern of case management and utilization review. But the time is ripe to shift this view of jurisdictional medical necessity by acknowledging that CDI as a profession plays a major role in proactively capturing documentation from the initial admission. CDI professionals can ensure the inclusion of context that accurately reflects physician clinical judgment, medical decision making and thought processes supportive of medical necessity. Unequivocal demonstration of medical necessity requires clear, concise, consistent, and congruent medical record documentation. The documentation must span from the initial patient presentation in the Emergency Room through the History & Physical, progress notes, consultant notes, nursing notes, ancillary care providers as well as the discharge summary. Too often, the discharge summary is a mere cut and paste of the H & P with scant content of the actual course of hospitalization – or even worse, the discharge summary consists of several sentences referring the reader to the H & P for further details.
Defining Medical Necessity
The concept of medical necessity is thought to be an arbitrary term subject to interpretation and second-guessing by outside third-parties in the name of “cost containment.” But even acknowledging the subjective nature of medical necessity from a reimbursement perspective, it can be easily defined from a clinical standpoint, utilizing the following documentation guidelines:
• Number, acuity, severity and duration of problems addressed by physician
• Extent to which comorbidities impact complexity in management of acute clinical conditions
• Context of previous management of same conditions
• Number of body areas and organ systems the physician must contend within clinical management
• Challenges and complexity of arriving at a diagnosis and development of a reasonable management action plan
All of these elements are directly vested in effective and complete clinical documentation, an area of focus and expertise in our profession. The gist of our duties and responsibilities as CDI specialist is to enhance the general quality of documentation so that it best communicates the patient care provided and delivered in our hospital. The byproduct of that effort – but not the goal – is ensuring fair and reasonable reimbursement from third-party payers for medically necessary services as evidenced by clear, concise, consistent and congruent documentation throughout the record.
In short, the degree to which the documentation effectively and accurately depicts the true representation of the “patient story” determines the extent to which medical necessity has been established in the communication of patient care. This includes communication to all healthcare stakeholders including the patient was well as third-party payers. The clinical facts and context as reported and documented in the Emergency Room and History & Physical serve as the foundation, and are instrumental in depicting the patient’s true severity of illness, risk of adverse events, and other mitigating factors and the need for hospital level of care that will span at least 2 midnights under the CMS 2 midnight inpatient rule.
Also of note: CDI specialists traditionally wait 48 hours (for workup and additional results to be available) for purposes of querying the physician for clinical documentation specificity. Yet that’s basically a reactive approach to CDI improvement that fails to materially improve documentation processes – not to mention the fact that it overlooks the opportunity to be proactive in securing documentation supportive of medical necessity.
Time to Evolve
With the celebration of National ACDIS week, there is no better time to ask ourselves both as a community and individually whether we are truly adding optimal value to communication of patient care. When we subscribe to the reactive versus more effective proactive approach to affect positive change in documentation process improvement, the fact is: we can do better, because we can do more. Reactive documentation improvement consisting of mere diagnoses without impacting and realizing any measureable change in process improvement cannot be considered “true” clinical documentation improvement. Yet by aiming higher, we can demonstrate not only our value to our employers, but our role in strengthening the continuum of healthcare information nationwide.