Clinical Documentation Integrity: Rebranding and Repurposing

CDI will be achieved through an unrelenting focus upon attainment of clinical documentation excellence. 

Clinical documentation integrity (CDI) programs are highly ingrained in most hospital and healthcare facilities. Career opportunities abound for CDI specialists who check job board sites and individual healthcare facility websites. A typical synopsis for job duties and responsibilities of a CDI specialist (CDIS) includes the following:

• Conducts admission/continued stay reviews accurately, using the coding guidelines and documentation guidelines to clarify conditions/diagnoses and procedures for which inadequate or conflicting documentation exists.
• Analyzes and interprets clinical data to identify gaps, inconsistences, or opportunities for improvement in the clinical documentation and appropriately queries the provider, using a compliant query based on American Health Information Management Association (AHIMA) guidelines for compliant query practice.
• Follows up on open queries to ensure physician response.
• Validates DRG assignment with medical record documentation, ICD-10-Official Coding Guidelines, and supporting clinical indicators.
• Facilitates and secures accurate clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients.
• Demonstrates knowledge of DRG payer issues, clinical documentation requirements, and referral policies and procedures.
• Develops collaborative relationships and promotes teamwork with co-workers and other departments.
• Maintains a positive and supportive attitude towards the mission and goals of the provider.
• Educates members of the team on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement opportunities and methods.
• Assists in educating physicians regarding documentation to the highest level of specificity for all conditions and complications being addressed and treated.

A Common Theme: Narrowly Defined Scope
A glaringly common element of most CDIS job descriptions is a focus upon diagnosis capture with associated reimbursement. The CDIS’s responsibilities center upon retrospective chart review, with the issuing of a query to clarify diagnoses that impact severity of illness/risk of mortality reporting, CC/MCC capture, and reimbursement. While I fully support current CDI initiatives to drive revenue improvement for hospitals facing ongoing revenue cycle headwinds, with payer margin compression and increasing patient financial liability with higher deductibles, this narrowly defined scope of work detracts from the profession’s ability to achieve CDI from a true “integrity” perspective. Recently, two associations representing the CDI profession moved to change from clinical documentation improvement to clinical documentation integrity, to reflect a renewed focus upon integrity of the record. Often, name changes reflect little substance, and this is no exception. The scope of work in the profession remains fundamentally the same: review of records for the purposes of increasing reimbursement, without associated improvement in the integrity of the record. Current CDI key performance indicators preclude actual achievement of real integrity of the record, from both a quality and financial perspective. Task-based indicators predicated primarily on the query process preclude the CDIS’s ability to engage in critical activities supportive of defined integrity.

The adage of “tell me how I am measured, and I will perform accordingly” applies in this instance. Attainment of performance measures such as number of charts reviewed and number of queries issued virtually crowds out the CDIS’s ability to engage in actual physician engagement and coaching opportunities that facilitate actual achievement of integrity. Many of my CDI colleagues feel stunted in their ability to affect positive change in overall physician behavioral patterns of documentation, sustainable over time, with this unrelenting focus upon task-based productivity measures. I submit to you that simply reviewing a record and issuing a query that is responded to positively by the physician, coding of records with an identified CC/MCC, and billing of an “optimal” DRG bears no resemblance to clinical documentation integrity.

Clinical Documentation Integrity and Clinical Documentation Excellence
Clinical documentation integrity must incorporate the recognition by the CDI profession that the medical record is a communication tool, first and foremost, and not a reimbursement tool, as today’s CDI model treats it as. We must respect the medical record with the patient in mind; our overall operating principle must consider the notion of the patient. The medical record content is all about the patient. The movement to CDI requires an updated mindset focused on achieving clinical documentation excellence on behalf of the patient, versus mere improvement. Improvement in diagnosis capture does not equate to clinical documentation excellence, which can be interpreted as the physician’s ability to become a high-performing communicator of patient care. Integrity requires, as a whole, redefining the current mission of CDI. What should the mission of CDI look like and consist of, for the purposes of coaching physicians in a quest to assist their becoming effective communicators of patient care, all while becoming more proficient in charting, saving precious patient care time?

The Mission of CDI: Moving in the Right Direction
The mission of CDI should include the following goals:

• To produce a medical record that is the most efficacious communication tool for all healthcare providers rendering care, in each case;
• To provide accurate, specific, detailed medical documentation to effect enhanced patient safety, as well as effectiveness of care efforts;
• To provide information for external reviewers of all types, free of ambiguity, inconsistency, or clinical incompleteness;
• To provide a medical record that is defensible relative to external audits; and
• To achieve the highest order of specific, accurate, detailed medical documentation to ensure the most precise final coding, so that the institution receives the optimal and appropriate reimbursement to which it is entitled, based upon the care provided and resources consumed.

CDI will be achieved through an unrelenting focus upon attainment of clinical documentation excellence. The three pillars of clinical documentation excellence are the following:

• The new paradigm of CDI may be defined as the completeness, consistency, organization, and accuracy of the medical record, reflecting the physician’s clinical judgment and medical decision-making. CDI supports positive outcomes in patient care, quality, cost, resource consumption, reimbursement, and revenue cycle processes.

• This new paradigm requires a wholesale shift in the mission of any CDI program, which should be aimed toward improving actual processes of clinical documentation and striving to achieve meaningful and lasting changes in physician behavioral patterns that optimally reflect communication of patient care, regardless of stakeholders, including third-party payers.

• By focusing too closely on reimbursement, we are overlooking the vitally important 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 stay, discharge stability, appropriate resource consumption, and utilization review/management processes under the Conditions of Participation, as well as the quality of care delivery, achieved outcomes, and accurate clinical validation of all assigned ICD-10 codes and DRG assignment.

Clinical Documentation Integrity: Repurposing and Rebranding
Considering all the medical necessity and clinical validation denials seen across the industry of late, as well as DRG and level-of-care downgrades from payers, clearly, the CDI profession is not achieving clinical documentation integrity in the strictest sense of the words. Most medical necessity denials are attributable to insufficient and/or poor physician documentation, something CDI is not currently addressing through the query process. Without medical necessity, there simply is no CDI, regardless of how you look at it.

If the CDI profession is committed to achieving integrity of physician documentation, then it must recognize the immediate, critical need to rebrand the profession’s processes and mission. To think that present-day CDI efforts are benefiting the patient, the physician, all healthcare stakeholders, and the achievement of a high-performing revenue cycle is a fallacy.

Won’t you please join me in an effort to transform CDI to a system that truly makes a difference in patient care, and the saving of our hospitals and our jobs, in this day and age of hospital closures?