Clinical Documentation: The True Value Proposition

From the December 2016 Issue

Clinical documentation improvement (CDI) programs have been established at most healthcare facilities for several years and in most cases can be classified as having achieved a mature status in terms of daily operations. These programs are similar in nature to any other service or product from a perspective of shelf lifecycle. Every successful service or product requires continual evolution and improvement to remain cutting edge, and CDI is no different.

The DRG prospective payment system introduced in 1982 by CMS led directly to the advent of CDI, which was initially a knee-jerk reaction aimed at revenue optimization under this new system. But in most respects, CDI has not altered its unwavering focus on revenue optimization, albeit masked as clinical documentation improvement.

And unfortunately, CDI consulting companies perpetuate the understanding of CDI as a “cash generator,” presenting it in this way to CFOs and revenue-cycle leaders in an attempt to validate the canned, off-the-shelf (and frankly worn-out) “Clinical Reimbursement Improvement” programs, circumventing the discussion of the need to develop new programs that meet the changing needs of documentation as the health system transitions into a quality-outcomes-focused delivery model.

Sowing the Seed
There are two major underlying themes of CDI that serve as a strong basis for enhancing the value proposition of our profession as CDI specialists.

The first underlying theme relates to the recognition, appreciation, understanding of and commitment to the words “documentation improvement” in our job titles and the direct impact we can achieve in best practices in the communication of patient care. We must always remain true to our devotion and passion for affecting positive change in overall physician behavior patterns of documentation, and recognize that our customers are the physician, the patient and all other healthcare stakeholders. And to be clear, our customers certainly include the CFO who has unknowingly and unwittingly been led to believe that CDI exists primarily to throw targets at the physician in the form of queries with the objective of capturing CCs/MCCs and supposed additional revenue through higher-weighted DRGs.

The second elemental theme relates to recognizing that promoting, making a compelling argument for, and achieving physician best-practice standards of documentation that serve as the underlying basis for a byproduct of compliant, accurate coding and billing. While reimbursement remains a byproduct of clear, concise and consistent documentation, we must remain cognizant of CDI’s prime supporting role in the revenue cycle-and ensure close alignment and integration through achievement of complete and accurate documentation.

Setting the Tone
Incorporating the underlying themes described above into our regular duties and responsibilities of CDI in a practical, meaningful manner requires developing and executing a sound strategy. One approach is to put in place the four Rs: revisiting, revising, refocusing and reengineering current CDI initiatives.

One may ask where-and indeed, whether-to start this process given that many of us are content with the present state of CDI in the sense that we’re comfortable in our current roles. Yet transforming CDI and moving the discipline into new waters that ideally and purposely advances the professional role we play in true documentation improvement is essential for our profession collectively and individually-not to mention the survival of our representative hospital employers as they adapt to the changing landscape of the healthcare delivery model.

Let’s take a deep dive into the specifics of the 4 R’s and examine how best to incorporate them into your CDI program.

Revisit — Take a hard look at the principles of CDI as it’s practiced today and recognize that what is referred to as “documentation improvement” is in reality the capture and securement of diagnostic buzzwords serving as CCs/MCCs and clinical specificity in principal diagnosis selection. While specificity of all diagnoses reporting is paramount to documentation improvement, effective reporting and reflection of the clinical content and context accompanied by the physician’s clinical judgment is essential from a communication of patient care and third-party payer regulatory compliance perspective. The proof of this is the growing volume of unnecessary self-inflicted medical-necessity denials, clinical-validation denials and DRG down-codes that result from our securing diagnoses not accompanied by sufficient documentation to unequivocally justify the clinical diagnosis.

Clinical validation became even more important with the October 1, 2016 ICD-10 official coding guideline changes, indicating the coder can assign a diagnosis based strictly upon documentation in the chart regardless of the existence and extent of clinical validation. We need to honestly interrogate the validity of querying for a diagnosis and the physician dropping a diagnosis in the chart and running to the next chart in search of another query opportunity that generates additional revenue. We must realize that this is commensurate with increasing the likelihood of a clinical-validation denial or DRG down-code. If we stand by as this occurs, our very value proposition is called into question.

Revise — Revise your organization’s understanding of CDI. Make a compelling argument to your leadership, including the CFO and revenue cycle leaders, on the true value and impact of quality documentation that we can achieve if given the opportunity to engage in “true” documentation improvement initiatives. A quick trip to your hospital’s denials and appeals department will highlight the volume and dollar magnitude of medical-necessity, clinical-validation denials and DRG down-codes attributable to insufficient physician documentation beginning in the Emergency Department and the History and Physical and transcending through the progress notes and discharge summary.

We are all undoubtedly familiar with note bloat, cut and paste and carry-forward practices that some physicians engage in — which come at the expense of the accurate communication of patient care. How many times have you perused a record and been unable to determine why the patient was admitted to the hospital in the first place? How often have you been left to wonder what, exactly, the physician was thinking in the moment — or how they envisioned the course of care proceeding?

Meaningful documentation improvement opportunities begin in the ED and H&P, documentation that includes CC, history of present illness, context of admission and physician assessment and plan of care congruent with the assessment and traceable back to the severity of signs and symptoms and nature of presenting problem as reported in the HPI.

These are just a few of the salient areas of documentation improvement requiring close scrutiny and intervention on our part. Physicians want to “do right” by closely approximating the complexity of patient care and actual work performed in their documentation; they just don’t possess a good appreciation and understanding of what constitutes sound documentation principles and techniques.

Refocus — This step entails refocusing our efforts to help physicians become attuned to, knowledgeable about and consistently adherent to the best-practice standards of documentation. We must first commit to learning and confidently operationalizing the best-practice standards of clinical documentation into our daily chart-review process. This requires becoming proficient at quickly recognizing and identifying what is an insufficiently documented H&P (versus a sufficiently documented one), as well as what constitutes an effective progress note and lastly what constitutes an effective and compliant discharge summary as required by the Joint Commission and the National Quality Foundation.

The onus is on us individually — and collectively — to undertake self-learning and develop a passion for understanding and interpreting the documentation we review. We must move beyond searching for CCs/MCCs — CDI is not an Easter egg hunt. Once we’ve gained a stronger understanding of sufficient documentation and the role documentation plays in the communication of patient care — and are confident in our abilities to promote this level and preciseness of documentation — we can move on to reengineering.

Reengineering — This is the culmination of efforts to transform your CDI program into a forward-thinking proactive approach that truly aligns and integrates with the goals, objectives and outcomes of the revenue cycle. While a tall order, the power to accomplish it is in our hands. We can ensure the record closely reflects the reason for patient care and relevant history; the physical examination findings and prior diagnostic test results; the medical plan of care and rationale for ordering diagnostic and other ancillary services; past and present diagnoses; appropriate health risk factors; and the patient’s progress, response to and changes in treatment, as well as revision of diagnoses. Also remember that rather than current principles of reactivity as evidenced by queries for diagnoses after the fact, being proactive is key to reengineering present CDI initiatives, transforming and enhancing the value proposition we bring to the table. In short, we can achieve even greater things for the physician, the patient and all fellow healthcare stakeholders.

Final Thoughts
We can no longer rest on our laurels when it comes to the performance of CDI efforts. Remember what happened to Hostess Twinkies and the ultimate demise of the company that made these delectable and unhealthy cakes. Another company is taking a stab at resurrecting the brand with a new marketing and sales approach — meaning the demand for the final product didn’t go away and the flaw was in the approach!

The primary goal — as we commit to and diligently work to transform CDI — is promoting and securing sufficient documentation. Our efforts will ensure that any provider can review a given record, understand the patient story, and deliver ongoing efficient care right where the prior physician left off. Time is of the essence — we must begin the journey now. We have much to do, and the scale of what we accomplish will depend on how soon we start.

Glenn Kraus is senior VP at ZirMed.