Understanding when and how to use clinical documentation integrity internal clinical guidelines (CDI-ICGs)

Clinical policies, clinical practice guidelines, best practice advice: there are numerous ways to refer to written recommendations designed to spell out how best to diagnose and treat patients based on the most current evidence. These are developed by expert panels of clinicians and scientists for healthcare providers. They are often crafted at the highest society or college level (e.g., American College of Physicians, Wilderness Medical Society, etc.).

In contrast, in the context of clinical documentation integrity (CDI), internal clinical guidelines (CDI-ICGs) refer to guidance statements created locally by an institution, organization, or network to help standardize clinical practice and documentation, attend to quality core measures, and bridge the coding-clinical gap. They may be facility-specific coding guidelines or best-practice, high-reliability medicine clinical guidelines. They may be developed de novo or adapted and drawn from already available external clinical practice guidelines. They may be proactive, or created in response to a coding conundrum. They may be triggered by new definitions or advances in medicine that are felt to be significant enough to warrant expedited dissemination through the medical staff.

Getting stymied while performing procedural coding may necessitate the use of CDI-ICGs. Say a provider is not being specific about the vessel he or she is using, or the type of contrast. Multiple queries for the same specificity result in provider, CDI specialist (CDIS), and coder frustration. Ask: “is there a default?”

If the answer is, “our department always uses the great saphenous vein when we can,” then have the department chief write a memo to the coding department to that effect, with the caveat that deviations from the usual practice must be documented. Defaults must be clinically valid – e.g., your hepatologists cannot whimsically declare that the caudate lobe is considered Segment V in your institution (there is a universally accepted classification for liver segmental anatomy https://radiopaedia.org/articles/couinaud-classification-of-hepatic-segments ). Do your breast surgeons document a position on a clock for site specificity? Get the coders on the same page with a CDI-ICG, with a diagram and coding instructions.

There may be CDI-ICGs that are aimed at CDISs. Specified types of schizophrenia, a chronic condition, serve as comorbid conditions/complications (CCs), whereas undifferentiated and unspecified types do not. The CDIS is informed by the establishment of an internal policy noting that if the patient is being treated with medications and specificity is lacking, a query should be generated.
However, the most challenging type of CDI-ICG addresses a clinical condition with both clinical practice challenges and documentation/coding implications. If it takes a consensus to make a publicly available statement, it may take a consensus in your institution to guide practice. If there is opportunity for auditors to deny a diagnosis, there is opportunity to give practitioners guidance regarding how to make and treat that diagnosis, and to do the same for CDISs and coders regarding how to elicit the proper documentation to support the correct code for the condition.

Creating a valid, adoptable, implementable CDI-ICG generally has three components:

1. A (often denial-prone) topic or diagnosis that does not have uniformly agreed-upon or recently changed definitions, and/or varying methodologies of diagnosis or treatment
2. Recognition that reduction of clinical variation is not the sole objective
3. Input from the right stakeholders.

The goal is to not diagnose a condition when it is absent, but to diagnose the condition when it is present, and to document it in a way that allows the coder to compliantly capture it.

Perfect examples of diagnoses that merit CDI-ICGs are sepsis, respiratory failure, and acute kidney injury. These are conditions with often misunderstood or easily misapplied clinical criteria, setting the stage for clinical validation denials.

Take sepsis, for example. One big recent change was dissociating the systemic inflammatory response syndrome (SIRS) from the diagnosis, but seasoned providers still cling to SIRS. This reflects the need for organizations to facilitate continuing education of their providers. Next, sepsis has a new definition, which corresponds to the condition formerly known as “severe sepsis,” with “severe sepsis” being eliminated from the clinical lexicon. If a provider represents sepsis-related acute organ dysfunction in his or her documentation, the coder is permitted to use R65.20, the code for severe sepsis, even if the provider hasn’t explicitly documented “severe sepsis.” This sets the provider up for falling out of core measures (SEP-1) if not attuned to this coding peculiarity. Suboptimal documentation may also preclude the use of that severe sepsis code, which will falsely deflate quality metrics.

When there are clinical guidelines, there is always room for clinical judgement. If a severely anemic patient has pneumonia with a respiratory rate of 32 and is having angina with ischemic EKG changes, but her oxygen level is 62 (exceeding the cited clinical criterion of pO2of 60), this could still be categorized as acute hypoxic respiratory failure. The provider needs to make the case explicitly in the documentation.

The biggest mistake organizations make in designing CDI-ICGs is not involving the appropriate people in creating the guidelines. Even the most knowledgeable physician advisor is not equipped to advocate for the integrity of every service line, so recruit nephrology or infectious disease or pulmonary/critical care, as indicated. Clinicians should not develop the CDI-ICG in a vacuum either, because they are not aware of all of the documentation and coding idiosyncrasies. If an institution finds a need to create a clinical protocol or pathway, quality and the CDI team should be consulted.

Coding and CDI attend to documentation requirements. Quality should be at the table to avoid patient safety indicator or core measure fallout. Utilization review/case management can ensure that the clinical criteria meet medical necessity. Don’t forget to involve information technologies to help design user-friendly technological solutions.

Think of the balloon analogy – when you squeeze one section, out bulges another distant area unexpectedly. Have all the right players in place to maintain the integrity of the balloon.

A strong caution: do not let the tail wag the dog. If an auditor cites some nonsensical dictum for which you cannot find clinical corroboration, like an assertion that reversal within 48 hours of treatment precludes acute kidney injury, or if they use ancient clinical criteria as the basis for a denial, like prealbumin in malnutrition, don’t alter your CDI-ICG as a reaction.

Someone must be tasked with keeping up with the changing external clinical guidelines so the CDI-ICG can be updated as needed. Always keep a record of prior versions, as you may need to refer to a previous CDI-ICG in the case of a delayed denial.

Dissemination of the information contained in a CDI-ICG may be better accomplished with an excerpt, like a CDI tip sheet. A blast email with the salient points could refer to the complete version housed on the hospital intranet. Hyperlinks could send the viewer from there to references, like the original external clinical guidelines or consensus paper.

Reducing clinical variation and improving quality of care should be considered of primary importance, and collaboratively developed internal clinical guidelines can assist in achieving that goal. Including CDI and coding in the process will ensure that the clinician and institution get credit for providing excellent quality of care.


Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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