Clinical Documentation Integrity Programs in the Spotlight

All hospitals are struggling to some degree, with increasing payer denials and ongoing post-payment chart reviews resulting in a time-consuming process. According to a recent Premier survey of 516 hospitals across 36 states, accounting for 52,123 acute-care beds, Medicare Advantage (MA) and Medicaid health plans denied initial claim submissions at higher-than-average rates of 15.7 and 16.7 percent, respectively.

Denials tended to be more prevalent for higher-cost treatments, with the average denials across payer types pegged to charges of $14,000 or greater. Despite significant rates of denials on initial claim submissions, the survey found that 52.7 percent of MA claim denials were eventually overturned, and the claims paid. Over half (54.3 percent) of denials by private payers were overturned and the claims paid, but only after multiple, costly rounds of provider appeals. While a sizeable number of these denials may be considered egregious, others may be categorized as legitimate. (Premiere Survey)

Current CDI Processes: Beneficial, or a Drag on The Revenue Cycle?

Current clinical documentation integrity (CDI) processes serve as a solid foundation for achieving true, sustainable documentation integrity. While programs continue to evolve to meet the increased need, the rate of transformation is not keeping pace to preemptively alleviate the onslaught of payer denials. A proactive, preemptive denial avoidance approach to achieving integrity that supports a high-performing revenue cycle must be the main goal of any viable CDI program. This approach is far more effective, requiring wholesale changes to present-day CDI processes.

Getting started, the CDI profession must take a holistic approach to chart reviews that encompasses a willingness to go beyond the typical, beginning the process with a commitment to improvement in emergency department provider documentation and communication of patient care.

The CDI profession must respect the medical record as a communication tool, collaborating with physicians and other providers as facilitators of complete and accurate documentation.

Complete and accurate documentation is defined by the Centers for Medicare & Medicaid Services (CMS) as the following:

• A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers. With these criteria in mind, an individual entry into the medical record must contain sufficient information on the matter that is the subject of the entry to permit the medical record to satisfy the completeness standard (Complete and Accurate Documentation).

The first step in beginning the long journey toward facilitating complete and accurate documentation is to migrate away from measuring the overall success of a CDI program by utilizing typical key performance indicators (KPIs) consisting of the number of charts reviewed, the number of queries issued, the physician response rate, complication and comorbidity/major complication and comorbidity (CC/MCC) capture rate, etc. These are little more than task-based activities that contribute to clinical validation denials, in many instances. Instead, the focus of CDI should be on collaborating with physicians and other providers, serving as a resource and guide, working hand in hand with case management, utilization review, physician advisors, denials and appeals, and coding to achieve better physician documentation. Measures of CDI success should include such measures as level-of-care downgrades, medical necessity denials, clinical validation denials, and DRG downgrades since the culprit of denials is insufficient physician documentation (also known as “Poor Documentation.”)

Payor Denials: CDI Rising to the Challenge

CDI plays a crucial role in payer denial avoidance by ensuring that medical documentation accurately reflects severity of illness and complexity of care provided to patients.

Here’s how CDI can contribute to reducing payer denials:

1. Accurate Documentation of Severity and Complexity: CDI specialists review medical records and work closely with healthcare providers to ensure that all diagnoses, procedures, and treatments are accurately documented. This helps in presenting a comprehensive picture of the patient’s condition, ensuring that the severity of illness is properly recorded. Payors often deny claims when documentation is insufficient or does not support the level of care billed.
2. Alignment with Coding Guidelines: CDI specialists ensure that medical documentation aligns with coding guidelines and standards set forth by payers. Correct coding is essential for claims to be processed without denials. By improving documentation accuracy, CDI helps in reducing coding errors that could lead to denials.
3. Educating Providers on Documentation Requirements: CDI professionals educate healthcare providers on the importance of detailed and accurate documentation. They provide feedback and clarification on documentation standards, ensuring that providers understand what information is necessary to support the services billed. This proactive education helps in preventing denials due to insufficient documentation.
4. Querying for Clarification: CDI specialists may query providers when documentation is unclear or incomplete. By obtaining additional information promptly, they help in ensuring that the medical record fully supports the services provided. This reduces the likelihood of denials based on insufficient documentation.
5. Reducing Compliance Risks: Insufficient documentation not only leads to denials, but can also pose compliance risks. CDI helps in mitigating these risks by ensuring that documentation meets regulatory requirements and industry standards, thereby reducing the chances of denials related to non-compliance.
6. Improving Overall Revenue Cycle Efficiency: Effective CDI practices contribute to a smoother revenue cycle by minimizing delays and rework caused by denials. This results in improved cash flow and operational efficiency for healthcare organizations.

In summary, CDI’s role in payer denial avoidance revolves around improving the accuracy, completeness, and compliance of clinical documentation. By doing this, CDI helps healthcare organizations submit claims that are more likely to be processed successfully, thereby reducing the incidence of denials from payers.