CDI professionals can’t mitigate the magnitude of medical necessity denials by third-party payers.

Clinical documentation integrity (CDI) programs, combined with the actions of third-party payers, can erode net patient revenue for inpatient and outpatient services through process design.

In reviewing one particular inpatient case with $118,000 in charges denied by the third-party payer on the premise of lack of medical necessity, I became more than convinced that CDI programs, while billing themselves as “integrity programs,” are in reality contributing to ongoing financial challenges due to their lack of emphasis upon achieving real improvement in the quality and completeness of documentation and communication of patient care.

This lack of focus by CDI programs and the current silo approach to CDI play a major role in the ongoing onslaught of costly, avoidable, self-inflicted medical necessity denials, resulting in increased costs to collect, increased bad debt, and decreased net patient revenue. There seemingly is not one day that goes by that I don’t read that a hospital is filing for bankruptcy, experiencing significant financial losses, and/or laying off staff related to significant financial shortfalls.

This beckons the questions of to what extent adverse level-of-care determinations and downgrades – as well as medical necessity denials, clinical validation denials, and DRG down-codes – play a contributing role.

Allow me to share with you the details of this $118,000 denial, and come to your own conclusions.

Case Details

The patient presented to the emergency department with shortness of breath and chest pain as the chief complaints. History of present illness, the section of the record that is crucial in accurately recording the severity of illness, appeared as follows:

  • Patient admitted with respiratory symptoms and has clinical evidence for respiratory distress, as evidenced by the use of accessory muscles and mild labored breathing. Patient has a green productive cough with no fever. Patient with known history of COPD continues to smoke more than a pack per day, 50 pack-per-year history, and has known hypertension, diabetes poorly controlled, and non-compliance with meds and follow-up with outpatient appointments. Course crepitations heard all over the lung fields. Harsh vesicular breath sounds are heard on the right side of the lungs. Breath sounds diminished on the right.

There are eight elements of a history of present illness (HPI) that are integral to the documentation of the patient’s presenting severity of illness, serving to reflect the nature of the presenting problem. Under Medicare’s two-midnight rule governing inpatient admission, the physician’s reasonable expectation of at least a two-midnight hospital stay is predicated by such complex medical factors as beneficiary medical history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event occurring during the time period for which hospitalization is considered. In other words, if the reviewer determines, based on documentation in the medical record, that it was reasonable for the admitting physician to expect the beneficiary to require medically necessary hospital care lasting two midnights, the inpatient admission is generally appropriate for payment under Medicare Part A. The HPI is defined as a chronological description of the development of the patient’s present illness, from the first sign and/or symptom or from the previous encounter to the present. HPI elements are the following:

  • Location (example: left leg)
  • Quality (example: aching, burning, radiating pain)
  • Severity (example: 10 on a scale of 1 to 10)
  • Duration (example: started three days ago)
  • Timing (example: constant or comes and goes)
  • Context (example: lifted a large object at work)
  • Modifying factors (example: better when heat is applied)
  • Associated signs and symptoms (example: numbness in toes)

As you can clearly see, in the critical part of the HPI that serves as a prism through which medical necessity is reported, the physician overlooked recording key elements that are fundamental to any patient who presents with chest pain and shortness of breath. A more encompassing effective reflection of a patient presenting with chest pain and shortness of breath may take the following approach:

  • Mr. Smith, a 65-year-old male patient, presented to the emergency department at 3 a.m., brought in by ambulance after having difficulty breathing. The patient is still smoking a pack a day and is on home oxygen 24/7 for chronic respiratory failure. Of note, the patient was just seen in ED four days ago and was diagnosed with acute bronchitis with concern for early pneumonia, and was discharged on Z-pack. The patient turned up his home O2 and still could not catch his breath; he then called 911. The patient was transported by ambulance to ED and was placed on O2 (six liters), arriving without incident. In the ED, the patient was still in obvious severe respiratory distress with accessory muscle use, two-word dyspnea, and complaining of associated chest pain with any movement, especially when breathing. Chest pain described as constant stabbing in nature at a pain level of 8 out of 10. The patient did receive breathing treatments and IV steroids but was still in distress, growing tired of work of breathing, and a decision was made to hospitalize the patient for further treatment of what I see as a clinical picture of early pneumonia with acute-on-chronic respiratory failure.

Crucial Elements that Truly Matter

As a matter of principle, the HPI should contain a minimum of four elements to best paint a picture of the patient’s story from the development of signs and symptoms to the time of patient presentation for care. An effective approach to address this is to partner with case management and utilization, working in tandem to advocate for a unified message with solutions for physicians. In today’s world, CDI is reviewing the chart for diagnoses while case management and utilization review are reviewing for admission, continued stay, and discharge planning.

Case management and utilization review are totally dependent upon the quality and completeness of documentation communicating patient care in order to effectively carry out their responsibilities in serving the patient and the physician as part of the care continuum. Clinical documentation integrity specialists are in the business of improving documentation; the synergies of partnering with case management and utilization review are real and powerful in achieving meaningful improvement in documentation that clearly demonstrates the clinical acuity of the patient, not only for initial hospitalization but also continued stay.

In the case above that resulted in a medical necessity denial, there was clearly insufficient documentation within the HPI as well as the physical exam and clinical impression. The physical exam listed the patient as “alert and oriented, speaking full sentences,” which is certainly not indicative of acute respiratory failure. In my personal CDI practice, this is a phenomenon of observations, and results of the examination of body areas or organ systems abound with disconnects between diagnosis in the clinical impression and the physical exam.

There are situations when there is a logical disconnect, yet the physician often does not include in his or her discussion of the clinical judgment the rationale and significance of the results of an exam and the diagnosis. Another point to consider in this case that certainly does not bode well, from a medical necessity perspective, is the fact that the clinical impression included a list of ruled-out diagnoses without inclusion of clinical rationale and relationship to radiology results, lab values, exam findings, and work up and treatments completed prior to time of hospitalization. The progress notes were a constellation of copying and pasting, with impression and interval history virtually the same every day. Ruled-out diagnoses continued throughout the stay when the CDI specialist (CDIS) queried the physician for a definitive diagnosis in a type of pneumonia, to which the physician responded with the diagnosis of cavitary pneumonia.

Unfortunately, this diagnosis was listed just once on the day of query, with the physicians resorting to copying and pasting ruled-out diagnoses. There were two consultants on the case, a pulmonologist and an infectious disease specialist, resulting in progress note documentation that lacked continuity and consistency, with the attending overlooking the opportunity to tie the clinical pieces together for a complete, clear, concise, and contextually correct patient story. Toward the end of the stay, the focus of workup and treatment turned to concern for anemia and a possible colonoscopy before the patient was discharged. The standard of documentation for the last progress note is to include a brief synopsis of the hospitalization, with documentation of all relevant diagnoses worked up and managed, providing a clear picture of the patient’s clinical stability. In this instance, the last progress note contained documentation of “see discharge summary dictated,” with the job number of the dictation in the note. There was no indication the patient was seen and examined by the physician on the day of discharge. Did I mention that the physician was also queried for acute respiratory failure at the onset of the visit, which certainly was not supported by the clinical facts, information, and context as documented in the record?

Final Thoughts

In retrospect, there is no doubt that insufficient documentation played a pivotal role in driving the financial repercussions of a $118,000 write-off as this hospital reached the end of the line in appealing this claim. The CDI profession cannot possibly mitigate the magnitude of medical necessity denials being issued by third-party payers, yet we can certainly make a sizable difference by partnering with case management, utilization review, and physician advisors, adhering to a unified, well-positioned physician message to achieve a level of documentation that stands for quality of care that aligns with the integrity of the revenue cycle. A first step is to step outside our traditional comfort zone of querying and acquire the skill sets necessary to share best-practice standards and principles of documentation that avoid costly medical necessity denials.

The present model of CDI, where the focus is upon chasing diagnoses and meeting all the statistical KPIs of CDI that bear absolutely no relevance to actual improvement in documentation, must be transformed to a more proactive model, where efforts are devoted to working with physicians as constituents to actually better the overall documentation process.

This model is not a utopia; instead, it is the reality. CDI in its present form unequivocally erodes net patient revenue, as the above case clearly demonstrates.


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