Clinical Documentation Integrity: Where Business Acumen Governs High Performance

Clinical documentation integrity (CDI) as a profession is quite similar in nature to running a business. Successful businesses exhibit certain operational qualities and traits that serve to ensure continued growth and prosperity, and their leaders possess a long-term vision and ability to consistently meet, exceed, and solidly predict current and future needs of their customers.

Incorporation of business acumen mindsets and principles into processes and operational decisions is instrumental in achieving high performance from a financial and competitive marketplace perspective. As clinical documentation integrity specialists (CDISs), we are operating a business within the business of healthcare delivery. There are specific duties and responsibilities we are tasked with that form the core basis for documentation improvement. Chart review, identification of potential documentation insufficiencies and/or inconsistencies, and the generation of clinical clarification queries when appropriate are germane and fundamental to such assignments.

Inarguably, there is certain degree of transactional repetitiveness associated with CDI in our quest to secure complete, clear, concise, and consistent documentation through the chart review process. There is one aspect of operating a business that is critical yet strikingly missing from the CDI equation, detracting from the professional’s ability to achieve optimal performance, return on investment, and close alignment and integration with the revenue cycle.

The Critical Missing Element

The critical element missing from the standard operations of CDI is the incorporation of the basic elements of business operations that increase the ultimate likelihood of success. Without the commitment to instill standard traditional business policies into our programs, we will never as a profession achieve the best possible performance for our organizations.  

What do I mean by this? Any successful business leader appreciates the importance of putting into play a forward-thinking plan of action to continually enhance efficiency and effectiveness; increase profitability with cost savings and expanded revenue streams; instill customer loyalty and commitment; and strive toward continuous quality improvement while securing a competitive position in the marketplace. A sound principle of business is adherence to the concept of SOWT:

• Strengths
• Weaknesses
• Opportunities
• Threats

Unfortunately, this business mindset – which is necessary for improving the quality and effectiveness of documentation – is largely missing in many cases.

Why is this? Operating a business requires absolute commitment to maintaining situational awareness. This includes understanding where the business presently is, where is it going, what the primary obstacles, true deliverable outcomes, and identified weaknesses and threats are. The question to ask yourself is this: are we achieving best performance? In some respects, we are conducting CDI in a vacuum, oblivious to the environment in which we operate.

Situational Awareness: A Best Practice Strategy

Situational awareness means continually looking out for potential threats in the marketplace, identifying and capitalizing upon trend-setting opportunities for documentation improvement, subscribing to the concept of proactivity versus reactivity, and addressing likely weaknesses and counterintuitive/counterproductive processes before they materialize. Let’s look at present-day CDI initiatives from a global perspective, drilling down to the theory of limitations that contributes to less-than-optimal achievement.

Current CDI revolves around the query process, with the notion that queries initiate a series of processes culminating in improved revenue capture through “maximized” ICD-10 coding. Key performance indicator components utilized in judging overall success are centered on the query process, i.e., number of queries issued, responded to, and responded to affirmatively. Other questions asked include whether the query was for a CC or MCC or principal diagnosis selection, and what the impact was upon reimbursement.

What is fundamentally lacking is measurement of whether diagnosis procurement translates into net patient revenue. This is particularly important given the heightened scrutiny by outside third-party payers determined to question and refute the validity of high-severity diagnosis based on “clinical validation.” Then there is the issue of specific documentation requirements often found to be lacking in the record, as identified by Centers for Medicare & Medicaid Services (CMS) Medicare Administrative Contractors (MACs) and Comprehensive Error Rate Testing (CERT) contractors in their prepayment and post-payment reviews of highly expensive procedures such as dual chamber/single chamber pacemakers, hip replacements, and automatic implantable conversion defibrillators, to name just a few. Lack of or insufficient documentation substantiating medical necessity for the procedures in the first place leads to unnecessary self-inflicted denials that can be quite costly.

Indisputably, the search for a secondary diagnosis in a CDI chart review that supposedly increases reimbursement capture serves no purpose when the entire stay generates no revenue and in fact costs the hospital significant sums.

An Incremental Approach to CDI

The profession of CDI must realize that we are operating a business requiring keen business skills, mindsets, and thought leadership. An unrelenting focus on present-day key performance indicators (KPIs) driving day-to-day CDI activities without instilling elements of business operations is an exercise in futility, detracting significantly from the value-add of CDI.

I call on CDI leadership to take the bull by the horns, take stock in your programs, and embrace and interject true business processes that meaningfully align with the revenue cycle processes of the hospital.

In short, CDI can support the hospital’s revenue cycle if we transition and operate our programs as a business. In my next article, I will outline the key steps to begin this journey.