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These foundational elements are essential to assure that there is a better way to improve CDI.

Clinical Documentation Integrity (CDI) programs continue to evolve over time with increasing utilization of artificial intelligence, computer assisted physician documentation, scribes, natural language processing and the like.

I fully support the application of these documentation tools that are coming to the marketplace in a concerted effort to assist physicians alleviate the ever-increasing administrative burden of practicing medicine. While the jury is out whether these documentation tools save physicians precious time, there is one thing that is certain that has been validated over time. The quality and completeness of the medical record with an accurate account of the true clinical patient story, capture and reflection of the physician’s clinical judgment and medical decision making, progression of care, and readiness for discharge including summary of care in the discharge summary, is not improving—this in the words of several of my physician documentation consultants and revenue cycle professionals.

Despite the penetration and existence of CDI programs in hospitals and all the solutions purported to improve documentation, the quality and effectiveness of physician documentation has failed to noticeably improve. All one must do is pick up a chart and experience first-hand the quality of the medical record beginning with the “history and physical.” Often, one does not receive a clear picture of the medical necessity for hospital level of care attributable to an insufficient telling of the patient story within the “history of present illness.” Medical necessity and clinical validation denials along with level of care and DRG downgrades from payers continue abated.

Further evidence that current CDI processes are not designed nor intended to achieve clinical documentation excellence can be validated by consistence results of the CERT contractor reports.  The most recent report shows that 79.9 percent of the Centers for Medicare & Medicaid Services (CMS) improper payments in 2021, similar to 2020, were attributable to medical necessity and insufficient documentation (2021 Improper Payment). Both the former and latter are directly related to poor physician documentation, something CDI purports to focus upon through the query process.

Unfortunately, queries accomplish little if everything in moving the needle in improving the integrity of the physician’s documentation. CDI queries unequivocally contribute to self-inflicted payer denials, freeing up the ball for the payer to hit it out of the park with denials.

More CDI generated queries issued equates to more payer denials. There is a “better way” to CDI, and it is incumbent upon the CDI profession to recognize the immediate need for transformation, creating a new path that truly supports and contributes to both patient care quality and the support of the revenue cycle.

Nine Foundational Elements of an Effective CDI Program

There are key and variable makeups of a transformative CDI program that effectively and efficiently drive real measurable meaningful improvement in physician documentation. First and foremost, before even considering “modernizing” one’s current CDI processes, one must recognize and subscribe to the philosophy that only the physician or other provider can improve the quality and completeness of documentation. The CDI profession can act as facilitators, mentors, and resources to physicians and other providers in driving improvement and integrity in documentation and communication of patient care. The following represents the “core elements” or foundational elements necessary to ensure overall success in working with physicians and other providers as colleagues and partners in realizing positive behavioral change in provider’s patterns of documentation. These nine foundational elements include the following:

  • Superior knowledge of best practice standards and principles of documentation as defined by Medicare. This includes up-to-date knowledge of current evaluation and management (E&M) principles but not only from an E&M code assignment standpoint.
  • Critical thinking skills in both clinical medicine and clinical documentation, expanding beyond the skills required to review a record and construct a compliant query;
  • Ability to review a medical record efficiently but effectively and identify true insufficiencies in documentation. Ability to intervene and address said documentation insufficiencies effectively with the physician or other provider;
  • Create documentation training tools and other resources for providers on best practices of documentation including the level and degree of documentation required for establishment of medical necessity for hospital level of care. Providers control the establishment of medical necessity through their documentation of the patient story and the capture of their clinical judgment, medical decision making and clinical thought processes.
  • Ability and interest in working and collaborating with physician advisors, case manager, and utilization review/management staff in the interest of clinical documentation integrity and quality patient care.
  • Treat and respect the medical record as a primary communication tool and a reimbursement medium as a byproduct of solid provider documentation.
  • Recognize the underlying premise of CDI is a patient advocate, working with physicians, other providers, and other healthcare stakeholders on behalf of the patient to improve the completeness and quality of documentation. Complete documentation facilitates fully informed coordinated quality focused patient centered cost effective care. The mere capture of diagnoses in today’s CDI world fails to address and achieve any of these key elements that factor into “quality care for the patient.”
  • Subscribe to the philosophy of continuous quality improvement with a commitment to continual learning, growth, and development. This goes well beyond the requirement to maintain CDI credentials with earning of a minimum number of CEUs.
  • Commit to working with physicians with the commitment to achieve a level and degree of proactive preemptive denials avoidance documentation versus querying for “naked diagnoses” without the supporting clinical story accompanied by the physician’s clinical judgment and medical decision making well put in the record.

These chosen elements listed above represent the “bare minimum” necessary to begin the long journey to a “Better Way to CDI.” 

CDI-Coming to Reality

The CDI profession must let go of the notion that capture of CCs/MCCs is the hallmark and mainstay of CDI. Current CDI processes are not achieving “clinical documentation integrity” under any sense of the imagination. If you think otherwise, you are either kidding yourself or not being true to the definition of “integrity.”

Consider the following from the most recent Kaufman Report titled “The Current State of Hospital Finances: Fall 2022 Update (AHA-Current State of Hospital Affairs)

  • Margins remain depressed relative to pre-pandemic levels.
  • More than half of hospitals are projected to have negative margins through 2022.
  • Expenses are significantly elevated from pre-pandemic levels.
  • Hospitals have faced a profound financial toll.
  • Ultimately, U.S. hospitals are likely to face billions of dollars in losses in 2022 under both optimistic and pessimistic models, which would result in the most difficult year for hospitals and health systems since the beginning of the pandemic with no foreseeable federal support.

These findings underscore the broad and serious threats America’s hospitals have faced—and continue to face in 2022— caring for their communities throughout unprecedented challenges

With the current challenging financial situation in most hospitals, time is of the essence to recognize and adhere to the urgent need to broaden the CDI’s scope of practice beyond reimbursement related task-based activities measured by present day Key Performance Indicators.

Today’s CDI activities must evolve into a role base that incorporates processes designed and intended to achieve true clinical documentation integrity from a compliance, patient care, and reimbursement perspective. The CDI profession, querying for financial impact, is not working for a variety of reasons as described above.

The time for change is now.

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