Moving in the Right Direction in Getting to the Root Cause of Clinical Documentation Improvement

The clinical query process is a small yet important part of any CDI initiative.

By now I am confident that most in the clinical documentation improvement (CDI) industry are familiar with the lawsuit brought by data analytics firm Integra against Providence Health to recover $188 million for alleged upcoding perpetuated by overly aggressive querying and guiding of physicians to document major comorbidities and complications (MCCs).

Physicians were allegedly encouraged to document secondary diagnoses that boosted reimbursement between $1,000 and $10,000 per case, according to the complaint. The three diagnoses cited in the lawsuit were acute respiratory failure, encephalopathy, and severe protein calorie malnutrition.

According to the complaint, Providence reported secondary codes for encephalopathy on 1,429 of 11,000 claims for femoral neck fracture, or 12 percent of the total, compared with just 4.5 percent for other hospitals that filed 1.1 million such claims. While one is innocent until proven guilty, let’s look at the underlying root cause that inarguably led to this lawsuit being filed.

While the clinical documentation improvement profession has evolved over the last 10 years, the structural foundation and processes of CDI have remained stagnant, with the query process constituting the status quo and hallmark of medical record chart reviews. The American Health Information Management Association (AHIMA), in cooperation with the Association of Clinical Documentation Improvement Specialists (ACDIS), has created Guidelines for Achieving a Compliant Query Practice, which were updated in 2016.

These guidelines address the entire spectrum of the query process, including when to query, how to query, and discussion of compliance in constructing a query (AHIMA 2016 Practice Brief Query Process). According to the practice brief:

• A query is a communication tool used to clarify documentation in the health record for accurate code assignment.
• The desired outcome of a query is an update of a health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment.
• The final coded diagnoses and procedures derived from the health record documentation should accurately reflect the patient’s episode of care.

The practice brief goes on to discuss “when and how to query” in the following context, stating that the generation should be considered when the health record documentation:

• Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
• Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
• Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
• Provides a diagnosis without underlying clinical validation
• Is unclear for present-on-admission indicator assignment

The Limiting Factor of CDI
The ubiquitous theme surfacing in nearly every discussion of CDI is the query process. Just look at the AHIMA or ACDIS list-serves and you will see countless questions and comments centering on the query process. There is even a benchmark, promulgated and promoted by CDI consulting companies, that establishes 30 percent as the standard for CDI to strive toward for query volume, taking into account an expectation of 20 to 25 charts per day. This effectively serves to relegate CDI to virtually nothing more than a task-versus-preferred role.

CDI is, simply put, not a manufacturing process whereby we are assembling widgets. Instead, clinical documentation improvement is a vitally important role that is clearly relevant to many disciplines involved in or associated with patient care, including utilization review/management, case management, quality, safety, social work, and denials avoidance, to name just a few. Chief financial officers (CFOs) have been misled and misdirected by various parties to view and treat the role of CDI as only a task, a means to an end. Hire and train CDI specialists, send them to boot camps, annual conferences, etc., herd them into a room, and allow them to listen to teleconferences and webinars on CDI-related rehashed topics that ultimately translate into more reimbursement: the outcome expected by CFOs. The thinking goes, hire more CDI specialists, then send out more queries to physicians, and the reimbursement goals established for the program will be attained. 

The CFO often assimilates this thought process out of being conditioned to believe and assume this is the standard in the industry. Unfortunately, this describes CDI in a nutshell, with the query process at the center of attention, driving an unrelenting quest for reimbursement. In fact, in a recent discussion with a CFO on the state of CDI, she was quick to point out her lofty financial goals for the CDI program in the next fiscal year. My immediate reaction that I refrained from sharing was “here is another CFO who is drinking the Kool-Aid, being misled into believing CDI exists strictly to achieve a greater level of reimbursement per case, like squeezing more juice out of an orange.” I am a firm believer in hospitals being reimbursed fairly and optimally for the right care provided at the right time in the right setting for the right reason with the right clinical judgment and medical decision-making with the right plan of care with the right clinical documentation. The right documentation must adequately reflect the patient story by clearly outlining the clinical facts, clinical information, and clinical context of the patient encounter in support of medical necessity. By focusing upon the query process for diagnosis, CDI is not addressing the crucial element of documentation representing complete and accurate communication of patient care. 

The time is ripe, now that ACDIS CDI Week has just passed, to realize that wholesale changes in CDI processes are essential if we wish to achieve excellence in depicting ourselves as experts in the field of documentation improvement.

Without disrupting the current status quo of CDI, we expose ourselves to obsolescence, as more and more services once provided in the hospital are now migrating to the outpatient setting.

The Responsibility of CDI as a Profession
The responsibility of CDI as a profession extends into numerous fronts, including partnering with other disciplines in the patient care delivery model, such as case management, utilization review/utilization management, social work, and quality. Partnering must go beyond lip service, requiring a strong CDI commitment to developing a deep understanding of the roles each discipline plays in the overall scheme of patient care.

By gaining a keen understanding and appreciation of the contribution of each discipline, CDI will become knowledgeable of the unique documentation requirements we must strive to consistently attain. Equipped with the depth and breadth of documentation necessary for the communication of patient care to be considered fully informed, quality-focused and patient-centered, CDI specialists then must identify the skill sets, core competencies, and knowledge base they must acquire to become proficient at identifying and effectively addressing documentation insufficiencies in the record. This knowledge base is not amenable to off-the-shelf documentation training programs that are pitched as a panacea for excelling in the CDI profession. Instead, the CDI specialists must invest the time and effort to learn on their own. There is a myriad of resources on the Internet for becoming broader-based in recognizing best practice principles and standards of documentation. Numerous medical schools have readily available resources on their websites, geared towards residents, subjects such as how to write an effective progress note, what constitutes a comprehensive history and physical, what the common pitfalls and deficiencies in progress note charting are, etc.

In summary, CDI must stop resting on its laurels and come to terms with the notion that the query process, currently the hallmark of CDI, cannot be “clinical documentation improvement” in and of itself. The clinical query process is a small yet important part of any CDI initiative, serving as an integral piece complemented by direct physician knowledge-sharing of techniques of documentation that are time-saving while enhancing the quality and completeness in the communication of patient care.

Diagnosis reporting must be acknowledged as a byproduct of complete and accurate clinical documentation that serves the entire spectrum of healthcare, from the time of initial admission to the history and physical through ongoing treatment and progression of patient care, culminating in discharge and compilation of the discharge summary.

Do not let the widely pervasive, engrained sentiment of CDI as a reimbursement initiative deter you from transforming CDI into a model that embraces diagnosis capture as a byproduct of efforts to truly improve the value of the medical record to all patient care stakeholders, the patient, the physician, and the hospital.
Consider CDI as a true patient care initiative that embraces the concept of quality documentation as synonymous with quality, cost-effective medicine, designing a program that motivates physicians to do the right thing and improve the value proposition in healthcare delivery by ensuring adequate and complete communication of patient care.

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