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How CDI transforms documentation from a reimbursement perspective to a tool for patient care and support of quality-based, cost-effective, efficient healthcare.

Clinical documentation improvement (CDI) programs have become deeply ingrained in most hospitals as part of a purposely directed strategy to improve financial operations.

According to a survey conducted by Black Book research between April and September 2017, when findings were tabulated from 2,920 surveys received from 256 hospitals and 2,449 physician practices, 87 percent of responding hospital financial officers claimed that the biggest motivators for adopting additional CDI measures were to create improvements in case-mix index, resulting in increased revenues and the best possible utilization of high-value specialists (Black Book Survey).

The real irony in the CFOs’ linking CDI with revenue is that CDI specialists are not provided with the opportunity, expectation, or accountability for truly improving the foundational processes of clinical documentation in a sustainable manner. Unfortunately, CDI has been relegated to a task-based role of regular review of charts for the primary purpose of data-gathering in the form of diagnostic comorbid conditions/major comorbid conditions (CC/MCCs) and optimization of principal diagnoses, all in the name of jacking up the case-mix and associated reimbursement.

What should CDI specialists be focused upon? For starters, they should be paying attention to the quality and completeness of documentation. “Quality and completeness” can be defined as:

  1. A logical flowing of a record that clearly, concisely, and consistently reflects the patient’s chief complaint in his or her own words
  2. A history of present illness (HPI) that remains true to its referral as “present illness”
  3. The nature of the presenting problem, including the severity of illness equating to the intensity of service
  4. Physical exam congruent with the HPI
  5. Physical exam congruent with the assessment and plan
  6. An assessment congruent and traceable back to the HPI
  7. An assessment that includes when appropriate, clinically relevant provisional diagnoses indicating that the physician using his or her clinical judgment believe are possible, in light of the available clinical information, facts of the case, and context

This merely constitutes a short list of documentation requirements that, when any are absent or unclear, represents an opportunity for documentation improvement.

In short, the documentation standard we should be achieving through collaboration with physicians is the ability of any physician assuming care of the patient (i.e., a nocturnist assuming care from the admitting hospitalist) to easily understand the patient’s presenting complaint, what brought the patient to seek care at the hospital, what the attending clinically was thinking that led him or her to decide that hospitalization was required, where the patient is now, the clinical stability of the patient, present definitive and/or provisional diagnoses, plan of care, and thoughts regarding discharge.

While physicians in residency supposedly are exposed to clinical documentation processes consisting of how to perform and document a history and physical (H&P) exam and discharge summary, the fact of the matter is that most physicians require a refresher and continued guidance on principles of documentation.

Contrary to a recent exchange with a CDI professional who is an instructor, CDI can and must be willing to step up to the plate and be able to identify and address real documentation insufficiencies – and just plain poor documentation – in a constructive and proactive manner. This goes far beyond the present-day skill sets of most CDI specialists who basically possess core knowledge in traditional CDI processes taught in boot camps, consultant training, and education, along with materials covered in CDI conferences, webinars, and reference resources.

By the key performance indicators established for CDI programs that supposedly measure their success and progress, CDI has been and unfortunately will continue to be locked into reimbursement-based goals and objectives, driving the operational performance of the program. Unfortunately, this model as it currently stands represents a misdirected, non-functional approach in support of documentation improvement that is counterintuitive to meaningful realized shifts in behavioral patterns among physicians. Reactive, repetitive query-writing is a band aide approach to documentation improvement that fails to address the root cause of poor documentation.

Proceeding from Here to There?

The focus of documentation improvement should consist of working closely with physicians to share actionable knowledge and information on best-practice standards and techniques of documentation. First and foremost, the CDI profession, both collectively and individually, must commit to strategical methodical efforts at acquiring the core knowledge supported by developed skill sets and practical application. Setting the stage for this paradigm change to our present-day approach to clinical documentation improvement is the recognition that CDI goals require wholesale shifts in direction, meaning, and outlook. Appropriate optimal reimbursement must be viewed as a byproduct of solid, effective, clear, concise, consistent, and complete documentation, representing the telling and retelling of the patient story.

I advocate for a totally new approach to achieving documentation improvement that fosters sustainable results. What does this approach consist of? Let’s start by addressing and recognizing what documentation stands for the following:

  • The purpose of complete and accurate patient record documentation is to foster quality and continuity of care.
  • It is created as a means of communication among providers and between providers and patients, focusing on health status, preventive health services, treatment, planning, and delivery of care.
  • The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.

CDI should serve as a supportive resource in assisting physicians in achieving clinical documentation that accurately reflects each patient encounter and physician clinical service performed, regardless of care setting. Effective and complete documentation of each encounter is what CDI should be promoting as part of our overall vision. Evaluation and management (E&M) is defined as the exchange of clinically necessary information and the use of this information in the management of the patient. Expanding upon this is the development of a sound CDI value statement and objectives as a means of serving as the guiding principles of CDI. The following provides for a reasonable starting point in driving the necessary paradigm shift in CDI principles:

  • Value Statement: By securing a thorough and accurate patient health record, we will achieve the correct reimbursement for resource utilization, the highest quality measures and outcomes, superior communication between providers, and ultimately, high patient satisfaction.
  • Goals and Objectives: Promote and achieve clinical documentation that best serves to reflect the complexity of care, clinical medical judgment, medical decision-making, thought processes, and medical necessity.

Closing Thoughts

CDI in its present form is two generations behind in achieving the degree of clinical documentation required under the transition from fee-for-volume to fee-for-value. Introducing the concept of clinical validation into the CDI process does not change the fact that current structure of CDI has not materially changed in the last 10 years. We are spinning our wheels doing the same thing, expecting improvement in documentation that is not coming to bear.

Time and time again, when I conduct an assessment of 100-plus records reviewed by CDI specialists at hospitals with mature programs and seasoned staff, I see no measurable evidence of documentation improvement whatsoever beyond specific, reimbursement-related diagnoses popping up in the chart from time to time. CDI ultimately must recognize the need to migrate away from strict focus upon reimbursement-related activities consisting of repetitive tasks and embrace the notion of complete and accurate clinical documentation throughout the entire patient hospitalization.

CDI must embrace this critical need and take action to reengineer the profession to the extent we stand for facilitating and achieving excellent, consistent documentation. Secondly, CDI must closely align with the goals and objectives of the revenue cycle by promoting documentation describing the clinical context, content, and facts of each case, supportive of net patient revenue that stands the test of time.

We are in the business of transforming documentation from a billing and reimbursement perspective to one that views the record as a valuable communication tool for patient care and support of quality-based, cost-effective, efficient healthcare.

Program Note: Listen to Glenn Krauss this morning on Talk Ten Tuesdays, 10-10:30 a.m. ET. Register now.


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