The authors discusses the lawsuit against Providence St. Joseph Health Services for alleged upcoding.

Performance with a purpose must be the driving force for business operations, personal goals, work and life accomplishments, and personal choices. The concept of performance with purpose must be a fundamental foundation governing all aspects of life, incorporating integrity, honesty, ethics, and a commitment to doing the “right thing.”

I am sure most have heard about the lawsuit against Providence Health Services for alleged “upcoding” associated with overdocumentation perpetuated by the health’s systems clinical documentation improvement program under guidance from an outside clinical documentation improvement (CDI) consultancy. Allow me to share some thoughts on the current state of affairs in CDI in the hopes of provoking an open discussion on the direction the industry should be taking moving forward in order to ensure performance with purpose.


Is CDI Truly Performing?

In reviewing the lawsuit against Providence Health Services, it is clear to me that the alleged over-documentation practices carried out by the health system’s CDI program are certainly not typical in the profession. What is also clear to me is the validity of my longstanding contention that CDI as a profession is operating under misguidance regarding what defines processes and outcomes of clinical documentation improvement.

Today’s viewpoint of CDI centers around and is motivated unequivocally by outcomes of reimbursement, regardless of how you look at it. Every aspect of CDI process supports reimbursement as the primary endpoint. While I am not downplaying or negating the fact that every CDI program must be self-sufficient and generate revenue as an outcome of our efforts, case mix and reimbursement should be considered a byproduct of the achievement of consistently solid and complete documentation.

Here is the grave concern I have with current CDI processes: they promote and perpetuate a model of performance that lacks the ability to move the needle on quality and completeness of documentation necessary for quality-focused, cost-effective, patient-centered, outcomes-based care delivery. Think of the current CDI model as an Alaska fishing expedition for CCs/MCCs, driving outcome measurements consisting of reimbursement. Take a hard look at the industry-accepted key performance indicators (KPIs) supporting CDI and measuring effectiveness of individual CDI specialists in performing their duties and responsibilities in chart review: number of charts reviewed, number of queries left by the CDI specialists, physician response rate, physician agreement rate, and DRG reconciliation after coding. I submit to you this question: do these KPIs constitute reliable measures of clinical documentation improvement? Does the number of charts reviewed have any reasonable bearance upon improvement in the quality and completeness of documentation achieved, at the end of the day? The answers to these questions are a resounding “no.” The profession of CDI is too caught up in an arms race for reimbursement, and too dependent upon the CDI query process to realize that present processes of CDI represent performance without a reasonable purpose.


Getting Back on Track

Going down the right path in CDI requires an open mind and willingness to realize that what CDI is accomplishing today is nothing more than a short-term approach that is unsustainable over time. Rather than focus upon the smaller picture of diagnoses in the record, instead I advocate for committed focus upon the larger, holistic picture of treating the record as a communication tool for physicians to record patient care with their clinical thoughts, diagnoses, management, and progress. I define complete and accurate documentation in the spirit of effective communication of patient care as the ability of the record to demonstrate the right care at the right time for the right reason in the right setting with the right clinical judgment and medical decision-making, the right documentation, the right plan of care congruent with the assessment and the right medical necessity. This degree of documentation requires the embracing of wholesale changes in our current approach to chart review, including recognition of the need for equipping CDI specialists with the necessary skill sets, core competencies, and knowledge bases to perform charts reviews with real purpose.

Relevant skill-sets and core competencies include the ability to practically understand and apply principles of good documentation that best communicate patient care. The CDI professional must be able to review a record, recognize opportunities for meaningful improvement in documentation beyond diagnoses, and possess the ability to communicate with the physician on the merits or insufficiencies – and, specifically, how to address said insufficiencies with true physician engagement. The ability to capitalize upon the opportunity to achieve real improvement in documentation hinges on the ability of the CDI specialist to see beyond CC/MCC capture and engage physicians as willing participants in clinical documentation initiatives to the extent they seek out information that they can assimilate into their regular practice of medicine. My longtime experience in CDI has proven time and time again that incorporating into the message of documentation with physicians that the record serves as a communication tool first and foremost for their patients is the hallmark of creating a CDI vision that inspires physicians to really desire to become more proficient in this area.


Doing the Right Thing

Doing the right thing translates into developing a reasonable purpose that drives performance. For CDI, the purpose of chart review is to enhance the communication of patient care for all the right reasons.

Solid and complete physician documentation serves a myriad of constituents, including but not limited to the patient, the physician, and all relevant healthcare stakeholders, such as case management, utilization review, quality, and those directly or indirectly involved in the performance of the revenue cycle. I view the lawsuit announced recently against Providence Health for alleged upcoding as a catalyst for immediate change in present-day CDI processes to reflect performance with real purpose, beyond short-term gain of artificial increases in case mix index and reimbursement.

CDI continues to breed ongoing denials through documentation of diagnoses that are under increasing scrutiny by third-party payors for clinical validation, including acute respiratory failure, encephalopathy, and sepsis: the same diagnoses cited in the Providence lawsuit. Instead of focusing upon diagnosis capture, our performance should consider the outcome of achieving documentation that adequately reflects the patient story in sufficient detail to allow the next physician to assume care where the first physician left off. It is incumbent upon the CDI profession to come to terms with the need to collaborate with physicians as constituents in providing and reporting the quality of care, provided in a cost-effective, value-based manner. Let’s start by reorganizing CDI to represent a profession that subscribes to the philosophy of performance with purpose.


Program Note

Listen to Glenn Krauss report on this subject during this morning’s Talk-Ten-Tuesdays broadcast, 10-10:30 a.m. EDT.

Comment on this article


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)