Role-Based Versus Task-Based Clinical Documentation Integrity: A Major Determinant of Operational Performance

The CDI profession has failed to effectively articulate its value in the revenue cycle.

Role-based versus task-based business processes can play a major role in driving operational performance of any department or organization. From a business perspective, each department of a company or firm contributes to the overall success and profitability of the organization. The same principle holds true in healthcare operations, including individual hospitals and health systems.

Healthcare is a complicated model with a myriad of distinct functions and processes that must work in harmony as part of the delivery of patient care. In many ways, healthcare delivery is quite like manufacturing, wherein a deficiency or bottleneck in any one element of the manufacturing process contributes to costly rejects or rework.

Dr. Eliyahu Goldratt devised the Theory of Constraints, a concept applicable in both the manufacturing and non-manufacturing arenas. The Theory of Constraints is a methodology for identifying the most important limiting factor (constraint) that stands in the way of achieving a goal and then systematically improving that constraint until it is no longer the limiting factor.

So you are probably asking what relevance this theory of limitations has to the clinical documentation integrity (CDI) profession. Allow me to share my thoughts on the merits of the CDI profession, both individually and collectively, especially for hospital administrators, revenue cycle professionals, and all CDI leadership. The Theory of Limitations must be recognized and embraced at a minimum by CDI leadership, as they are pivotal in the long-overdue transformation of CDI processes to drive operational performance of their departments, in support of an efficient, highly performing revenue cycle. Today’s current challenging financial environment imposed by the COVID-19 pandemic dictates immediate reorganizing of present-day CDI processes that basically remain largely unchanged since the inception of CDI over a decade ago.

Revenue Cycle Fundamentals
The revenue cycle is defined as all administrative and clinical functions that contribute to the management, and collection of patient service revenue. In the most basic terms, this is the entire life of a patient account, from creation to payment.

Fundamental to the revenue cycle  is physician documentation and communication of patient care. Physician documentation is the cement serving to hold the entire revenue cycle together, from the time an order is placed or a service is provided until the time the encounter is assigned ICD-10 and CPT codes and billed (and either the claim is paid or denied by the payor). A major limiting factor in the revenue cycle is the physician documentation supporting all facets of the healthcare continuum.

CDI programs were introduced over a decade ago, and promoted by CDI consulting companies as a means of addressing widespread physician documentation insufficiencies. These programs are still being operated by the majority of hospitals, with the intent of driving physician documentation integrity.

But CDI programs are nothing more than a short-term quick fix for goosing up the case mix index through diagnosis and complication and comorbidity (CC) and major CC (MCC) capture and reimbursement. The hallmark of CDI is the query process, which can be transactional and repetitive in nature, overlooking the strong potential to change physician behavioral patterns of documentation over time. Physician documentation quality has yet to improve over the last decade, since the inception of CDI. The proof is in the pudding: nearly 80 percent of improper payments made to hospitals for fee-for-service Part A inpatient hospitalizations are attributable to medical necessity and insufficient documentation, per the 2019 Medicare Fee-for-Service Supplemental Improper Data Report (CMS Improper Payment). Insufficient physician documentation has been and continues to be the limiting factor in achieving and maintaining optimal revenue cycle performance. Medical necessity and clinical validation denials, as well as DRG and level-of-care downgrades, are particularly problematic, detracting from foregone collection of desperately needed revenue as hospitals and health systems try to address significant shortfalls as a result of the COVID-19 public health emergency. One CFO in a recent conversation referred to CDI as “CRI:” clinical reimbursement improvement, which exists only in a theoretical manner, versus a practical manner. Finally, a CFO that understands the severe limitations of current CDI processes within the revenue cycle.

CDI: Stepping Up Its Game
How can the CDI profession step up its game and make tremendous inroads in addressing ongoing physician documentation shortfalls, under the auspices of the Theory of Limitations? How can the CDI profession reformat current CDI processes and its stated mission to improve the integrity of the medical record? After giving these questions much thought, I have come up with the following ideas:

• Recognize and treat the medical record as a communication tool, first and foremost, versus a primary reimbursement tool.

• Focus upon physicians as partners and constituents in any clinical documentation improvement initiative, versus targets for queries, with the intent of squeezing more money out of every chart.

• Take the time to identify and address every physician’s unique educational training, learning, and knowledge deficit needs in best-practice standards and principles of documentation and charting. If all physicians just want to know what diagnosis “buzzwords” to use in the name of increased reimbursement for the hospital, it’s an issue.

• Acquire the skill sets, knowledge, and core competencies in best-practice standards and principles of documentation and charting that can be confidently shared with physicians.

• Operate under the reasonable premise that CDI can truly help physicians work smarter, not harder, when it comes to documentation and charting, allowing them to spend more time with their love of medicine versus doctoring in front of the computer. We must recognize the simple fact that the query process only adds to physician administrative burden, so let us be part of the solution to reduce administrative burden by lessening reliance on it.

• Recognize clinical documentation integrity as a career versus a mere job and a means to earn a paycheck. Commitment to continual learning in clinical documentation practices and requirements of payors that continually evolve over time is essential to maintaining relevance in the profession, as well as to our employers and physicians.

• Reject the notion that CDI is task-based, as perpetuated by customary key performance indicators (KPIs), including the number of charts reviewed, number of queries left, number of queries answered by physician, CC/MCC capture rate, etc. These task-based KPIs bear no resemblance to and do not reasonably measure improvement in documentation, let alone integrity. CDI is role-based, with specialists working with physicians’ boots on the ground to affect positive change in documentation quality that is sustainable over time.

• Recognize that CDI software, while essential, must be considered a tool, as opposed to crutches, in the scheme of operational processes. Skill sets and core knowledge of the CDI professional, with intelligently operationalized CDI processes that engage physicians as willing participants in becoming more proficient in documentation and charting, represent the foundation for program success.

• Implement CDI leadership that embraces visionary mindsets, thought processes, and continuous quality improvement activities, versus the traditional leadership model hinging around task-based CDI.

Seizing the Moment
Time is of the essence in today’s challenging financial climate, as hospitals are struggling, waiting for CDI to transform itself. Business as usual, consisting of repetitive, transactional queries, is not a viable option, when you consider that current CDI processes have accomplished virtually nothing (if anything) in achieving clinical documentation integrity. There has been a name change to “integrity,” with lip service paid in achieving any sense of the word in documentation and revenue preservation. The profession must resolve itself to reformulate our mission, if we are thinking of the future of the profession, and that of our hospitals. All hospitals are wrestling with deteriorating financial pictures, yet the CDI profession is steadfastly clinging to old-fashioned processes, investing in expensive software under the contention that things will change.

Let me perfectly clear: time has demonstrated that continuing to do the same thing over and over and expecting new results has not been effective in achieving any clinical documentation integrity. I submit to all CDI professionals, and especially CDI Leadership, change is needed for the better for our patients, our physicians, our healthcare stakeholders, our careers, and the fiscal health of our hospital facilities.

Programming Note: Listen to Glenn Krauss report this story live today during Talk Ten Tuesdays, 10 a.m. EST.