The query process is no substitute for education and training.
The hallmark of any true clinical documentation integrity (CDI) program consists of medical record chart review by clinical documentation integrity specialists (CDISs) with a goal of identifying gaps in diagnosis specificity as well as addressing other deficiencies requiring clinical clarification. Some of these deficiencies include clarification of present-on-admission indicators or hospital-acquired conditions, elements that impact reimbursement to some degree.
Over-Reliance on the Query Process
As time has progressed, the CDI profession has become over-reliant on the query process, to the degree that other valid, reliable processes of documentation integrity are simply being overlooked. Several key points that merit mention are related to why the clinical query process is counterproductive to realizing meaningful, measurable integrity in the quality and completeness of documentation. These include the following:
The query process is simply no substitute for good old-fashioned education and training, with hands-on instruction and sharing in real time best-practice standards and principles of communication of patient care. Queries are a repetitive, transactional, reactive means of capturing diagnoses and/or clarifying timing of diagnoses, and generally, they are ineffective in achieving long-term change in physician behavioral practices of documentation. Substantiation of this assertion of lack of change in documentation patterns rests with the ongoing, unrelenting querying for type and acuity of congestive heart failure. This ranked as the number one diagnosis for querying on a recent Association for Clinical Documentation Improvement query survey – this despite the fact that increased code specificity in heart failure has existed for more than five years.
Queries accomplish little in improving the quality and completeness of the medical record, or in furthering the accurate communication of patient care that other healthcare stakeholders are directly dependent upon (and at the mercy of, in fulfilling their responsibilities on behalf of the patient).
What do I mean by “quality and completeness” of the medical record? Phrasing this another way, what expectations does a patient have for encompassing documentation that effectively communicates the care provided, that ensures and contributes to the right care in the right setting at the right time for the right reason with the right clinical judgment and medical necessity with the right documentation and plan of care? In a recent conversation with a close relative, I learned that his spouse was in the hospital with supposed pneumonia after returning from an overseas vacation. I proceeded to ask him the following questions, thinking like a true clinical documentation integrity specialist should, in reviewing a record:
- What was wrong?
- How did it manifest? What were the presenting signs and symptoms when she presented to the emergency department after first presenting at the urgent care clinic and then being referred there?
- What was the “history of present illness” (HPI) – what is the story of the wife’s condition from the time she became ill until she presented to the ED?
- What care did the wife receive in the ED?
- How did she look at time of the decision to admit to the hospital?
- How does she look lying in the hospital bed?
- What were the physician’s thoughts at the time of the decision to admit to the hospital? What are the provisional and/or definitive diagnoses and why?
- What is the current plan of care, and what is the plan for discharge?
The husband proceeded to request a copy of the ED record, as well as the history and physical, which he and I reviewed. He was so surprised to learn that we were not able to answer a good number of these questions. Of note was that the attending ordered a pulmonology consult for guidance and assistance in management.
From a perspective of quality of communication, the other physicians as well as case managers and utilization review staff are at the mercy of the documentation driving authorization of the hospitalization, appropriate clinical guidance, and management and plans for any continued stay and discharge plan of care. The above bullet points serve as a strong foundation for establishing complete and accurate documentation at the time of admission. I recognize first-hand the severe handicaps that utilization review and case management face without sufficient clinical documentation that depicts a clear picture of the patient’s clinical status at time of hospitalization. Consulting and treating physicians require a solid, clear, consistent, contextually correct patient story to perform their best in their practice of medicine on behalf of their patients. Diagnoses play only one small part in the larger scheme of patient care, and effective communication of patient care is the building block of quality medicine.
Where Queries Miss the Boat
Clinical documentation integrity initiatives play a major role in the revenue cycle of each hospital by potentially enhancing the quality of the communication of patient care. There is much discussion on how CDI assists with quality reporting, yet this quality reporting relates to outcome measures that are often openly questioned as to their validity and reliability. CDI as a profession can capitalize upon the opportunity to achieve solid, quality-focused documentation that truly resonates and represents the quality of care achieved. I have outlined several key elements of quality documentation above. Complete and accurate clinical documentation effectively communicating the care provided, while certainly serving the needs of the patient, the physician, and the multitude of healthcare stakeholders, also best supports the revenue cycle.
This quote from an article titled “Clinical Documentation Improvement Solutions Up Provider Revenue” that appeared in the Revenue Cycle Intelligence Newsletter CDI Solutions really resonated with me in regard to the current value proposition CDI currently brings to the table versus what it can bring to the table. The article outlined key points gleaned from a recent KLAS Research survey of healthcare executives, medical records directors and managers, and other decisionmakers in new report titled “Clinical Documentation Improvement 2018: Workflows and Prioritization Drive Quality and Financial Outcomes:”
- Revenue improved for about 53 percent of those surveyed.
- Approximately 38 percent of respondents also reported improved workflow efficiency, and 19 percent said reporting accuracy and metric tracking improved.
- Fewer healthcare leaders and decisionmakers, however, are realizing financial gains in the form of increased acuity (18 percent), improved documentation quality (16 percent), fewer full-time equivalents (3 percent), and reduction in payor denials (1 percent).
Reading between the lines, 53 of the respondents surveyed reported greater revenues, yet clinical acuity, documentation quality, and increasing payor denial issues, including medical necessity and clinical validation denials. An important point to keep in mind is that revenue increase does not necessarily equate to net patient revenue increase; any revenue increase reported is presumably gross patient revenue. Net patient revenue is the key performance indicator to focus on as a reliable and true measure of CDI program success.
Queries that generate diagnoses, as evident in the survey response results, do not lend themselves to driving down payer denials or improving documentation quality. Documentation quality is what drives down and impacts third-party payor denials through better telling of each patient story, inclusive of the clinical facts, clinical information, and context pertinent to the encounter. In many ways, queries contribute to denials through inconsistency of documentation. Auditors can have a field day and refute the diagnosis, often a diagnosis that is the only complication or comorbidity (CC) or major CC (MCC) listed.
Are Queries the Answer for CDI?
While queries are a mainstay of CDI, the most beneficial approach that achieves the likelihood of greatest success is commitment and dedication to working hand-in-hand with physicians, sharing practical information on methodologies and techniques best serving the communication of complete and accurate patient care. Effective documentation begins with the ED record, goes on to the HPI and progress notes, and culminates in a discharge summary that truly summarizes the patient encounter and care provided. Let’s really offer some serious thought to taking a long look at our programs and advocate for transformation in our approach to CDI.
Listen to Glenn Krauss report this story on Talk Ten Tuesday this morning at 10-10:30 a.m. ET.