In many ways, CDI is the perpetuator of self-inflicted denials through the query process. 

Unprecedented times require unprecedented actions, with all hospitals and health systems currently facing undue financial stress related to the ongoing (and raging) COVID-19 pandemic.

The American Hospital Association (AHA), in its report issued June 30, indicated that the financial strain facing hospitals and health systems due to COVID-19 will continue through at least the end of 2020, with total losses expected to be at least $323 billion for the year. (AHA Report). Of note is that this projection may underestimate the magnitude of realized losses, as it does not consider the continued widespread rise in the number of COVID-19 patients that is occurring throughout the country. Those in the healthcare arena are all too familiar with ongoing hospital furloughs and layoffs as a direct result of the pandemic, with facilities trying to proactively address financial shortfalls, as well as balancing increasing expenses with decreasing revenues. Managing and retaining a talented workforce represents approximately 60 percent of hospital costs (Hospital Labor Costs).

All Hands on Deck

My previous published articles on ICD10monitor centered on the emergent need for transformation of current clinical documentation integrity (CDI) processes rooted in complication and comorbidity/major complication and comorbidity (CC/MCC) diagnosis capture, primarily focusing upon patient admissions with the opportunity for “enhanced” reimbursement.

While I certainly am not by any means downplaying the necessity for hospitals to get paid fairly for the patient care provided, commensurate with patient’s clinical acuity and resources consumed in serving the patient’s clinical needs, today’s unprecedented times require critical action from hospital administrators. Today’s once unthinkable financial challenges in healthcare are now reality, with no end in the foreseeable future. This requires an “all hands on deck” mentality to overcome and address, if hospitals are going to financially survive and successfully get over this monumental hurdle. Every time I learn about a hospital closing or laying off or furloughing staffers, I ask myself the question of what hospital is next. I know personally of numerous colleagues in the CDI arena laid off in the last two months alone, due to reductions in force.

So, what do I mean by “all hands on deck,” and what is this critical action hospital administrators must take to address significant financial shortfalls, aside from resorting to downsizing and reductions in force? The C suite must recognize and address the significant opportunities to shore up revenue streams, with an eye towards optimal net patient revenue that will be preserved over time, alleviating the onslaught of continued medical necessity and clinical validation denials, coupled with DRG downgrades and financial recoupments (sometimes years after receiving initial reimbursement from the payor). The secret sauce for moving in the right direction in preserving revenue that the hospital is entitled to and must collect is recognizing and capitalizing upon the opportunity to transform the process of denials management to denials avoidance. Denials management is synonymous with inherent, avoidable inefficiencies in the revenue cycle, embracing the notion that it is simply okay to accept that denials are a regular part of the revenue cycle that must be contended with, an added expense budgeted for in the finances of the hospital. This mentality aligns with the following quote from a physician colleague of mine, spoken as we were discussing the very subject of avoidable costly medical necessity denials:

  • “If you don’t have time to do it right the first time, you don’t have time to do it right to begin with.”

Measure of medical necessity and clinical validation denials may be a proxy for preventing serious defects in the quality and completeness of documentation. These defects are self-inflicted and self-perpetuating, continued every day, despite the fact that most hospitals and health systems have invested heavily in CDI programs, from a consulting, staffing, and technology perspective alike. Why is it that notwithstanding the existence of these entrenched CDI programs, documentation quality and completeness – a fundamental component and prerequisite for establishment of medical necessity, as well as support of all diagnoses documented, coded and billed – are not improving?

A Reasonable Explanation

A reasonable explanation for the continued unabated denials is that CDI programs, as a whole, in their present format, were not designed nor intended as a mechanism to actually achieve improvement and integrity of the physician’s documentation and communication of patient care. When the overall approach to CDI is predicated primarily upon treating the medical record as a reimbursement tool versus a communication tool for patient care, wherein appropriate optimal reimbursement is a function of clear, concise, consistent, contextually correct, and consensus-driven physician documentation, hospitals will never come out ahead; providers will always win.

Hospital administrators, by accepting the status quo in present-day CDI program processes, are allowing desperately needed revenue to slip right through their fingers. Insufficient documentation, also known as poor documentation, and the practices that allow for it, will continue to fester without overdue transformation in CDI processes, consisting of queries as the hallmark of most programs.

Traditional key performance indicators (KPIs) used to measure overall success of a CDI program have no correlation with meaningful, measurable, and sustainable improvement in documentation integrity. Simply put, these KPIs are measures of task-based activities that do not promote nor achieve improvement in true documentation integrity that generates revenue falling to the hospital’s bottom line. As long as the C suite continues to use the current KPIs as measurement of their CDI program, with present CDI processes, the more revenue the hospital allows to continue to slip through the cracks.

CDI: There Is a Better Way!

CDI that generates optimal net patient revenue, with preservation, consists of modifying the current approach of an unrelenting focus upon CC/MCC capture. This approach has long outlived its shelf life; what really matters is moving the needle on the quality and completeness of physician documentation through program redesign.

The first step in this journey to recovery is for the C suite to open the hood, kick the tires, and refuse to accept on face value the program results CDI leadership is providing every month. Stellar KPIs provided to the C suite are mere measures of task-based activities, associated with “feel-good” monies the hospital may or may not collect (or, if collected, may not be retained after payer scrutiny). Track monthly medical necessity and clinical validation denials for which CDI reviewed the record and secured a CC/MCC diagnosis. This is a potential measure of current defects in the hospital’s CDI program. In many ways, CDI is the perpetuator of self-inflicted denials through the query process.

Allow me to leave you with the following takeaway points:

  • Current CDI processes require total transformation.
  • CDI transformation, rejecting the status quo, is a sound financial strategy to address continued financial stressors of all hospitals and health systems.
  • Medical necessity and clinical validation denials will continue unabated without transformation.
  • Without adequate documentation that reflects the patient’s clinical acuity with solid clinical information, medical necessity is elusive. Without medical necessity, CDI is irrelevant.
  • CDI cannot improve integrity of the documentation by themselves; it requires a team approach, breaking down traditional silos in the revenue cycle.
  • Time is of the essence, so act now.

My next article will provide informative insight on how best to get started in the CDI transformative process.


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