Where CDI went awry: missing an opportunity for safety.

In last week’s ICD10monitor news edition, I authored an article titled “How a Texas Health System Beat a $61.8 Million Billing Fraud Case.” The dismissal of the case was based upon a citation of previous language the Centers for Medicare & Medicaid Services (CMS) used in a final rule that on face value promotes “maximizing Medicare through taking advantage of coding opportunities supported by documentation in the medical record.”

Unfortunately, the clinical documentation integrity (CDI) community is assuming that the language used to toss out the whistleblower lawsuit sanctions the misguided approach to CDI that has remained virtually stagnant for the past 12 years. The profession as a whole remains steadfastly committed to task-based CDI activities that do not necessarily yield maximized outcomes, consisting of optimal net patient revenue through the code and DRG assignment process.

Let’s take a look at a case I reviewed this week wherein the payer denied a claim for $220,000 based on the premise of lack of medical necessity.

When Narrow Focus Can Be Detrimental
I was requested by a client to review this hospital case wherein the payer denied a 34-day inpatient stay for lack of medical necessity, again, to the tune of nearly $220,000, potentially devastating to a small community hospital already faced with a dire financial situation due to its payer mix and location in the community. After reviewing the case on the merits of patient clinical acuity and need for hospital level of care, with undue reservation, I found myself informing the CFO of the hospital of the bad news: this case was a total loss, with absolutely no chance for appeal. I will highlight the key points of the physician’s documentation within the record, in conjunction with the clinical information and facts, in addition to the context of hospitalization that contributed to this unfortunate financial debacle.

The patient was a frail 92-year-old  with hypertension and chronic vascular dementia who was transferred to the hospital from a nursing home for ongoing nausea and vomiting. The patient was transferred to the emergency department (ED) without incident and was evaluated and assessed, then subsequently admitted.

A quick review of the ED physician documentation revealed questionable need for hospitalization. Next I proceeded to review the attending’s history and physical for clinical clues of what brought the patient into the hospital (i.e., asking what was wrong with the patient, what the clinical picture looked like, and how it manifested). The first item on the agenda was to invest the time to review in detail the history of present illness (HPI), where the clinical facts, information, and context are customarily included (or should be included) as an integral role in establishing medical necessity. Medical necessity is fundamental to any service ordered by the physician, especially an order for hospital level of care. An accurate and complete HPI consisting of eight distinct elements is germane to establishing medical necessity for this purpose.

As CDI professionals, we must hone in on the patient story as described in the HPI, which is 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 are 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)

As I read the patient’s HPI, reviewing the clinical information and facts of the case as documented, culminating in the physician’s assessment and plan of care, I was clearly convinced that the hospital’s likelihood of success in overturning the denial through the appeals process was basically nonexistent. The HPI, in a nutshell, described a patient story whereby the patient was stable, had no real complaints, and did not even have any current nausea or vomiting. Here is a quick summary of the HPI, physical exam, and clinical impression with plan of care:

  • HPI: Mrs. X, a 92-year-old patient from the nursing home, was brought to the hospital for supposed ongoing nausea and vomiting. The patient states that she is not actively having any nausea and vomiting, but the patient is a poor historian due to chronic vascular dementia. She says she feels fine and is not quite sure why she is here in the hospital. She does have a history of chronic gastroenteritis with nausea and vomiting, with questionable swallowing difficulties, but no swallow test or workup performed, as far as I can see in the computer. Of note: she was hospitalized about a month ago for a similar presentation and now she is back.
    • Physical Exam:
      Constitutional: BP 110/60, RR 18, temperature 99 F, HR 75, O2 sats 94          
      • Room air, patient alert and oriented, in no obvious distress

          Lungs: CTA

          Heart: Regular rate and rhythm, no gallop, no murmur

          Extremities: No pitting edema, no rashes

          Abdomen: Abdomen not distended, no guarding or rebound

          Skin: No rashes, good skin turgor

Workup Completed: All labs WNL with no temperature, WBC 5.6, X-ray shows no acute disease


  1. Acute-on-chronic gastroenteritis
  2. Nausea and vomiting
  3. Dehydration
  4. Dementia
  5. Hypertension


Plan: IV Zofran, IV Fluids for dementia and hypertension, continue meds

The Next Steps
I proceeded to review the next few days of progress notes, and they included more of the same, with no obvious clinical acuity. Of note is the plan for a swallow study, which the patient failed, and then a plan for the gastroenterologist to perform an EGD. All of these interventions may be performed on an outpatient basis.

Now, I am really perplexed how case management may have missed the boat on this case, not working with the attending physician to clarify any additional information to support and justify the need for hospital level of care. On day four, the CDI specialists initiated a query (well, not so much an official query, but instead a note to remind the physician to include any provisional or definitive diagnoses that may explain the patient’s acute-on-chronic gastroenteritis with nausea and vomiting). I commend the CDI professional for the reminder note left for the physician to consider provisional diagnoses for a patient’s signs and symptoms, pending further workup, as being essential in the crux of capturing the physician’s clinical judgement, medical decision-making, and thought processes, all relevant to the establishment of medical necessity for planned patient work-up and admission and continued stay. On the other hand, the CDI staffer missed an opportunity, in this case, to reach out to the case manager and suggest a revisiting of the level of care, based upon available physician documentation and clinical information.

Aftermath: A Downward Spiral of Vacuum Mentality
What transpired, in this case, was the patient was admitted to hospital in the incorrect level of care, as it appears on face value that the progress notes were a compilation of copied and pasted notes with identical HPIs. The patient’s condition worsened, as she became hemodynamically unstable, necessitating transfer to the ICU, and ultimately, she died, with the acute systolic CHF, pneumonia, and sepsis overwhelming the patient’s body reserve.

The long and short of it was that the CDI’s second set of eyes and ears certainly may have played a positive role in the case manager engaging in a discussion with the attending to update the physician order and level of care – and possibly redirect the physician’s workup as an outpatient. As it stands, the hospital now has a $220,000 bill that will be classified as bad debt, with the reporting of a patient who died with a lower-severity condition: certainly not indicative of the quality of care and quality measures overall.

What this case signifies to me is the critical importance of CDI as a profession, and the need for expanding the breadth and depth of our chart reviews, embracing a vision of documentation integrity beyond the mentality of “taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.” The keywords here are “supported by documentation in the medical record.”

In my mind, accurate and complete clinical documentation and communication of patient care is the area CDI must acknowledge as the priority of any chart review, working with physicians and all other ancillary healthcare professionals to drive real measurable improvement in documentation beyond diagnosis capture. Diagnoses quite frankly don’t mean much in the telling of a patient’s clinical story, in the overall scheme of the revenue cycle, when the hospital is denied payment from third-party payers. It is particularly disheartening when a facility is not effectively addressing the root cause of most medical necessity denials and adverse level-of-care determinations through efforts to drive achieved enhancement of the quality and completeness of clinical documentation.

CDI programs can be a formidable force in improving clinical documentation to the extent that any outside reviewer or physician can read and gain a clear understanding of the patient story, what the physician is thinking and why, and where the physician is going from a plan of care and discharge perspective. CDI programs should not view the recent whistleblower case as a victory for the profession. Instead, the profession should transform itself for optimal performance.


You May Also Like

HCCs: The Role of CDI and Risk Scores

HCCs: The Role of CDI and Risk Scores

Predicting coding patterns using the HCC risk scores can be a valuable endeavor. EDITOR’S NOTE: Longtime RACmonitor contributing correspondent Frank Cohen, a senior healthcare analyst,

Read More

Leave a Reply

Your Name(Required)
Your Email(Required)