Facilitators in Communication of Patient Care versus Clinical Documentation Improvement Specialists

Creating a new vision for CDI.

There has certainly been much discussion in the revenue cycle community regarding the “I” in CDI, with the idea of changing clinical documentation “improvement” to “clinical documentation integrity.”

Rather than centering on “improvement” versus “integrity,” though, fundamentally, the discussion should focus upon defining what the profession stands for and represents. I have always supported and embraced the notion of clinical documentation improvement is a misnomer and fallacy. After recently conducting a thorough review of 25 inpatient records, all denied based upon the contention of lack of medical necessity, I am even more convinced that neither clinical documentation improvement nor clinical documentation integrity represents an appropriate title for the profession. Allow me to explain and outline my rationale with specific thoughts and case examples associated with this chart review.

A Limiting Factor: Lack of Medical Necessity

A client requested that I review these 25 inpatient records and provide an assessment of the legitimacy of third-party payor denials based upon medical necessity. Upon review, it was quite evident that every one of them lacked medical necessity for inpatient hospital care. The limiting factor, as is customary in a large number of medical necessity denials, based upon firsthand experience, is insufficient and/or poor clinical documentation.

Yes, there were diagnoses in the records, clearly documented and even clarified by the clinical documentation improvement specialist, yet the care was denied on the basis of medical necessity for inpatient level of care. How can that possibly be the case? For starters, the patient story, beginning in the emergency department, moving into the history and physical (as well as the progress notes), and culminating in the discharge summary, lacked detail and specifics. An accurate and complete patient story was simply not well-executed.

A well-told patient story allows the reader to gain insight into the patient encounter, outlining in clear, succinct detail why the patient sought medical care. Such a story is only as solid as the sum of its parts, with one deficient link impacting the quality and accuracy of the entire thing.

The patient story typically begins with the recording of the patient’s chief complaint, or CC. The chief complaint is a concise statement that describes the reason for the patient encounter. The CC is usually stated in the patient’s own words. For example, you’ll see that a “patient complains of upset stomach, aching joints, and fatigue.” The medical record should clearly reflect the CC. Often, in these records, I found that either there was no chief complaint recorded, or the chief complaint was recorded as a diagnosis, such as acute exacerbation of chronic obstructive pulmonary disease (COPD). I think we can all agree that such a chief complaint would not correlate with the patient’s statement when inquired by the physician.

The next crucial part of the patient story is the history of present illness (HPI). A 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 include 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 large object at work)
  • Modifying factors (example: better when heat is applied)
  • Associated signs and symptoms (example: numbness in toes)

There are two types of HPIs: brief, which consists of one to three elements, and extended, which consists of four or more elements. A great patient story consists of at least four elements. An all-encompassing, detailed HPI is instrumental in reflecting the patient story, setting the tone for the establishment of medical necessity for inpatient hospital level of care, establishing for the physician on behalf of the patient the need for physician work, including evaluating and managing the patient and ordering of treatment and/or diagnostic workup. Insufficient and/or incomplete HPIs play an overwhelming factor in many a medical necessity denial, not to mention the ability of the case manager/utilization review specialist to best perform the important role of advocating, for the physician and patient, for the most clinically appropriate level of care from the payer.

Let’s take a look at two cases that were denied, and highlight the deficiencies that certainly contributed to a determination of lack of medical necessity by the third-party payor.

Case One

  • Chief complaint: not completed
  • HPI: This is a 57-year-old woman with a history of chronic mental illness admitted from the emergency department feeling depressed and having suicidal thoughts, without any plans. The patient reports using drugs, her father is terminally ill, she is not compliant with her meds, and has frequent admissions with poor family support.

Case Two

  • Chief Complaint: Abdominal pain
  • HPI: This is a 75-year-old female patient who presented to the emergency department after calling 911 for shortness of breath. She says it started last night, and she is complaining of abdominal pain as well. She is being admitted for further workup, evaluation, and management

Both of these cases were denied as inpatient hospitalizations for lack of medical necessity. Granted, these cases beckon the question: where was case management and utilization review when the patient was admitted? When I consulted with the physicians who admitted these patients to seek additional clinical information in conducting an appeal, I received pertinent information that served to describe the true patient story in such fashion that there was clear severity of signs/symptoms and clinically valid concerns to warrant an inpatient admission.

The chief complaint and the HPI are the first piece of the story the clinical documentation improvement/integrity specialist should be focusing upon, from a patient storytelling perspective by the physician. Identifying opportunities for enhancement in communication of patient care extends well beyond diagnosis capture; emphasizing and attempting to capture a diagnosis before ensuring complete and accurate depiction of the patient story is analogous to putting the cart before the horse.

Logically speaking, focusing upon capturing diagnoses without working with physicians through formation of a strong alliance with case management/utilization review and other ancillary healthcare stakeholders is lesson in indisputable futility.

A More Efficient and Effective Model: The Facilitator in Communication of Patient Care

Coming back to the idea of clinical documentation improvement versus clinical documentation integrity, CDI professionals must recognize the immediate need to update our vision of CDI, for the sake of enhancing the value we can bring to the table. Considering the present role of CDI, we are tasked with reviewing medical records, identifying opportunities for clarifying overlooked or nonspecific diagnoses, and querying the physician, with our success measured by arbitrarily created key performance indicators (KPIs) that are simply transaction-based. In reality, these KPIs fail to live up to the name of CDI, as there really is no improvement in documentation.

Increasing numbers of medical necessity denials, clinical validation denials, and DRG down codes attributable to poor and/or insufficient documentation is clear testimony to the notion that documentation is not improving. In many ways, clinical documentation is worsening, as physicians engage in more point-and-click, use of drop-down menus, and copying and pasting.

Rather than being passive reviewers of the medical record, I fully advocate a clearly more effective model, wherein CDI professionals become active participants in efforts to improve the effectiveness and completeness of clinical documentation. Basic to this premise is the need for digression away from frank diagnosis capture toward becoming facilitators in the communication of patient care that best reports the patient story, as well as the physician’s clinical judgment and medical decision-making.

If you think about it, the only individual who can improve the communication of patient care is the physician. Today’s present model of CDI serves primarily to clarify diagnosis reporting based upon the available information in the record. What is clearly missing in this process is efforts that really move the needle in terms of communication of patient care by the physician – to the mutual benefit of the patient, the physician, and all relevant healthcare stakeholders, in addition to the hospital’s revenue cycle performance.

This pressing need to update the scope, breadth, and vision of CDI to one embracing facilitators in the communication of patient care is shared by many of my revenue cycle colleagues. My philosophy is this: physicians truly are dedicated to improving their communication of patient care on behalf of the patient.

Unfortunately, present-day CDI processes are infused with the unrelenting belief that measures of the effectiveness of CDI programs are reported in case mix index (CMI) increase, with an associated increase in reimbursement, creating a counterintuitive environment.

A Closing Remark

The CDI profession is at a pivotal juncture. Continue down the same path, wherein one follows the traditional processes of CDI like a herd, or roll up your sleeves and design a program to support the transition to CDI as a role-based profession, not a task-based, repetitive, transactional, reactional model.

I include the aforementioned facilitators in the communication of patient care as an integral component of any program to enhance the value of communication of patient care. Essential to transitioning away from current models of CDI to those which achieve performance with purpose, sustainable over time, measurably improving communication of patient care while engaging physicians, is unwavering support of CDI leadership. CDI leadership has a vested interest and duty to recognize the immediate need for taking a hard look at current CDI processes and developing and creating a well-thought-out plan to produce far better outcomes.

I challenge CDI leaders to make a real difference; great leaders don’t follow, instead, they lead.

“The task of the leader is to get his people from where they are to where they have not been.” -Henry Kissinger

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