Opportunity Abounds for CDI – So Seize the Moment!

New guidelines from the AMA provide the groundwork for physicians to follow in accurately capturing their medical decision-making (MDM), which includes their clinical judgment and thought processes.

Jan. 1 has brought us new evaluation and management (E&M) guidelines for inpatient and observation encounters. Will the clinical documentation integrity (CDI) profession capitalize upon the opportunity to incorporate critical physician documentation education and knowledge-sharing, important and relevant to E&M, into their workflows?

These guidelines do not establish documentation requirements or standards of care, as the American Medical Association (AMA) has reinforced. What the guidelines accomplish is to lay out the groundwork for physicians to follow in accurately capturing their medical decision-making (MDM), which includes their clinical judgment and thought processes. CDI can certainly play an instrumental role in driving real clinical documentation integrity by reinforcing these new guidelines to physicians as an integral component of daily chart reviews.

Administrative Simplification

The new E&M guidelines for inpatient and observation are a continuation of the AMA’s goals to streamline mechanisms of E&M coding and billing, as it did in the 2021 E&M outpatient office guidelines, striving to have processes more closely reflect the physician’s actual regular practice of medicine. Let’s take a high-level review of the new E&M guidelines and pinpoint how the CDI professional can truly work with physicians as constituents and partners in assisting them to achieve real clinical documentation integrity. These new guidelines reinforce the fact that physicians are the only ones who actually can improve the quality and completeness of the documentation, as opposed to CDI specialists. The CDI specialists can serve as a guide, mentor, facilitator, and resource to the physician, providing the physician with the tools and know-how to put to regular practical use while documenting and charting in the electronic health record (EHR).

Overview of 2023 Evaluation and Management Guidelines

There are three key major components of an E&M encounter, consisting of a history, physical exam, and MDM. Prior to 2021, for outpatient office visits, and starting in 2023 for inpatient/observation, the physician was required to adhere to the specific rigid documentation bullet points for each key component. Post-new E&M guidelines, the key component of E&M is MDM or time, depending upon individual unique circumstances of the patient encounter. Under these new guidelines, all that is required for the history and physical components is a medically appropriate history and physical; they are no longer required bullet points. A medically appropriate history and physical is based upon the physician’s clinical judgment and the nature of the presenting problem. Decision-making is a key activity in patient–physician encounters, with decisions being the outcomes of such activity. Decision-making can be regarded as the cognitive process resulting in the selection of a belief or a course of action among several alternative possibilities (National Library of Medicine). Clinical judgment is defined as the physician’s assessment of a patient’s particular clinical scenario and the initiation of action congruent with the assessment.

Looking at E&M from a physician patient encounter perspective, it may be defined as the exchange of clinically pertinent information between the patient/caregiver/other, and the use of the information in the management of the patient. A well-conveyed patient encounter must read like a novel, with an introduction, the history and physical, and then an emphasis upon the history of present illness (HPI). The body of the novel consists of progress notes, and the conclusion consists of the discharge summary. MDM represents the crux of medicine, where the physician collects and reports his/her assessment or clinical impression in the form of definitive and/or provisional diagnoses. The new 2023 E&M guidelines for inpatient/observation, similar to the 2021 outpatient office E&M guidelines, break out MDM into three main components as follows:

  • Number and complexity of problems addressed;
  • Amount and complexity of data to be reviewed, analyzed, and interpreted (my addition); and
  • Risk of complications and/or morbidity or mortality of patient management.

MDM is the limiting factor in physician documentation, and charting in the electronic health record contributes to level-of-care downgrades, as well as medical necessity and clinical validation denials. The common theme to these adverse determinations by the payer is insufficient and/or incomplete physician documentation within the assessment and plan.

Where CDI Can Make Its Mark

Clinical impressions or assessments often contain just a compilation of acute and chronic diagnoses, with the absence of much-needed reporting of the physician’s clinical judgment, thought processes, and clinical rationale used in arriving at a definitive and/or provisional diagnoses. By virtue of the absence of this critically important clinical information, payers are provided with the ammunition they need to clinically challenge the physician’s diagnoses based on clinical validation. Each acute diagnosis within the assessment should include but not be limited to the following:

  • Relationship to patient’s signs and symptoms;
  • Abnormal physical exam findings/observations to clinically validate the diagnosis, including vital signs;
  • Abnormal clinical results and diagnostic workup completed thus far to support the diagnosis;
  • Any workup and treatments in the emergency department, with patient response that clinically supports the diagnosis; and
  • A statement by the physician as to why he/she believes that the patient has a specific diagnosis in the face of some expected normal clinical findings, such as pneumonia in the face of a normal chest X-ray.

In short, documentation of a history and physical should resemble a roadmap, with a starting point and an end point, beginning with the HPI, which must contain at least four elements to adequately describe the patient’s clinical story, with accurate reporting of the patient’s severity of illness, necessary to help support medical necessity for a hospital level of care. The physical examination must be clinically appropriate as indicated and outlined by the E&M guidelines. In addition, the physical examination, as reported by the physician, must reflect the nature of the presenting problem, as described by the physician in the HPI.

I call your attention to the constitutional part of the physical exam. Often there is a clinical disconnect between this, the patient story within the HPI, and the acute diagnosis within the assessment. A case in point is a recent case in which the physician documented acute hypoxemic respiratory failure within the assessment, yet documented under the constitutional part of the physical examination, “alert and oriented X 3, in no acute distress, resting comfortably at the end of the bed watching TV, just finished off a cheeseburger and fries, stating looking forward to dinner.” A clinical validation denial by the payer is almost guaranteed in such a case.

Getting Started – Becoming the Facilitator of More Effective Documentation

The CDI professional unequivocally can play a major role in assisting physicians to practically apply the new 2023 E&M inpatient/observation coding guidelines, even if they offload the actual code assignment to a coding professional. Accurate, complete, optimal ICD-10 diagnoses and E&M assignment is directly proportional to the quality and completeness of physician documentation. The profession can assist physicians in becoming fully knowledgeable of the principles of 2023 E&M guidelines if we become the key resource to physicians in these same principles.

Taking it one step further, we must understand the direct correlated relationship between standards of documentation that fully support effective communication of patient care, acquire this knowledge and the ability to educate our physicians, and lastly, be able to successfully incorporate this into daily our daily chart reviews.

I encourage all CDI professionals to seize the moment, step up to the plate, and operate at the top of our game in CDI. Stepping outside our boundary of comfort levels will deliver a handsome return on investment for the CDI profession, both individually and collectively.


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