Searching for Efficiency in the CDI Process

When efficiency is not truly efficient, after all.

“Efficiency” may be defined in many ways, including the following, as described by dictionary.com:

• Able to accomplish something with the least waste of time and effort; competency in performance.
• An accomplishment or ability to accomplish a job with a minimum expenditure of time and effort.

Now, let’s look at efficiency in relation to the profession of clinical documentation integrity (CDI). The operational process of CDI consists of the CDI specialist (CDIS) opening a chart within the electronic health record (EHR) , reviewing the physician documentation and the diagnostic workup thus far completed, as well as treatments given, interpreting the clinical information available, and ultimately identifying “missing diagnoses” or non-specific diagnoses, culminating in a query to clarify. The standard in the industry is to review 25 records per day and achieve a 30 percent query rate, with an 80 to 85 percent response rate from physicians. CDI software has become prevalent in the industry, with more and more hospitals utilizing it to enhance overall “efficiencies” in the chart review process.

“Efficiency” in this context translates into performing more record reviews in a given day, prioritizing those charts with the greatest opportunity for documentation improvement. The logic is that the more records CDISs can review in a day, the greater the opportunity to identify a standard or major complication or comorbidity (CC/MCC) and potentially optimize the Medicare Severity Diagnosis-Related Group (MS-DRG), reimbursement, and case mix.

This thought process is not rooted in logic, as I will further explain. More CDI staff leaving more queries undoubtedly leads to more medical necessity and clinical validation denials, based upon my firsthand experience and analysis of CDI programs of several clients.

When Efficiency is Not Truly Efficient
I mentioned in a recent ICD10monitor article the highlights of the 2018 Centers for Medicare & Medicaid Services (CMS) Improper Payment Supplemental Data Report. The improper payment rate stands at 8.1 percent, with an estimated $31.6 billion (yes, billion) paid improperly. Nearly 84 percent of the improper payments were attributable to either insufficient documentation or lack of medical necessity. In the Part A inpatient segment, the improper payment rate was 4.8 percent, with projected improper payments at $8.6 billion. Insufficient documentation and lack of medical necessity accounted for 87 percent of the improper payments in the hospital setting.

To put this in proper perspective, CDI utilizes software to enhance efficiencies in chart review processes, yet still, an estimated $8.6 billion was paid improperly, with $7.4 billion attributable to insufficient documentation and lack of medical necessity.

A common denominator to both insufficient documentation and lack of medical necessity is poor documentation, something CDISs deal with firsthand every day in their activities, yet they are not charged with nor held accountable to actionably address it and improve. In a nutshell, the more records CDISs review, the greater the potential for increasing medical necessity and insufficient documentation issues, given the fact that the current operations of CDI are not designed for (nor intended to) effectively improve the quality and completeness of documentation and communication of patient care. Unequivocally, I support the use of software as part of a larger strategy to effectively improve communication of patient care, communication that truly improves the accuracy and completeness of the medical record to the extent that the reader gains a clear picture of the patient story (and can find the patient in the story).

A common line of thinking was to look at this by referring to Sir William Osler’s sensible quote: “the good physician treats the disease; the great physician treats the patient who has the disease.”

Today’s CDI model helps the physician treat the disease, through clarifying and securing of a diagnosis. The critical piece lacking in most CDI programs is the facilitation of a clear, concise, consistent, complete, and contextually correct patient story, with the patient evident in the story.

There is not a day that goes by I don’t review a medical record and wonder what the patient is doing in the hospital, yet I see a query for clarification of a diagnosis. This defies any logic and contributes to medical necessity denials based upon insufficient documentation.

Software enhances efficiencies in chart review, provided that the CDIS is afforded the opportunity to partner and collaborate with case management and utilization review, as well as the physician, to drive real meaningful improvement in documentation beyond diagnoses.

Driving Home the Point
In reading the Supplemental Data Report, I picked up on Table D4, Top 20 Service Types with Highest Improper Payments: Part A Hospital IPPS (Inpatient Prospective Payment System). A quick glance at the table indicates that within the 20 top services are common DRGs that CDI clarifies through the query process, particularly the DRGs with CCs or MCCs. Here are some of the common top 20 DRGs with improper payments:

• Major Joint Replacement or Reattachment of Lower Extremity (469, 470), insufficient documentation 91.8 percent (wow!)
• Endovascular Cardiac Valve Replacement (266, 267), insufficient documentation 84.6 percent
• Septicemia or Severe Sepsis (871, 872), incorrect coding 64.6 percent (insufficient documentation equates to incorrect coding)
• Renal Failure (682, 683, 684), medical necessity 80.1 percent
• Simple Pneumonia (193, 194, 195), medical necessity 64.6 percent
• Esophagitis, Gastroenteritis, & Digest Disorders (391, 392), medical necessity 77.9 percent
• Respiratory Infections and Inflammation (177, 178, 179), medical necessity 72.1 percent
• Syncope and Collapse (312), medical necessity 96.9 percent
• Chest Pain (313), medical necessity 98.8 percent

The Evidence is in – CDI Must Transform
Efficient processes in CDI dictate that some type of CDI software be utilized as a fundamental part of any program. Just the same, the software must be viewed and treated as a tool to reduce the hassles and administrative burden associated with tracking and trending the progress and results of the CDI initiative. CDI software supports efficient CDI operations through the reduction of manual processes that detract from productive CDI activities. My real concern is that software will be perceived as a panacea for driving success in CDI, defined as the ability to review more cases that have a higher likelihood of improvement in documentation, translating to more queries generating more CC/MCCs captured, supporting higher case-mix index and revenue.

Herein lies the problem with that rationale: without impacting quality and completeness in documentation, the tendency for more medical necessity denials as well as clinical validation denials rises to the forefront. Reviewing more records, placing more queries, yet not ultimately generating real net patient revenue is a lesson in futility that offers a minimal return on investment. It is my sincere hope that CDI leadership, the associations representing the CDI profession, staff CDI, and CFOs come to their senses and recognize that CDI software is only as valuable as the staff using it and the established processes ingrained as an integral part of the CDI initiative.

Unless current structural processes, skill sets, and core competencies are evaluated and transformed to fully achieve meaningful documentation integrity, the performance of any program in affecting positive change in patterns of documentation will never materialize.

CDI today is not truly CDI without the ability and accountability to facilitate effective communication of patient care. Only the physician can improve the documentation; CDI is relegated to simple clarification through the query process, made more efficient through software applications.

Programming Note:
Listen to Glenn Krauss report this story live today on Talk Ten Tuesday, 10-10:30 a.m. ET.