CDISs urged to be prepared for changes.

There is much to do on listserves and various conversations with colleagues to be had regarding the Centers for Medicare & Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS) proposed rule for the 2020 fiscal year, wherein Medicare has outlined sweeping changes to the current complications and comorbidities (CCs)/major CCs (MCCs) list. In total, there are 1,492 code change proposals, including the following:

  • 183 Non-CC to CC
  • 1,148 CC to non-CC
  • 8 CC to MCC
  • 17 MCC to non-CC
  • 136 MCC to CC

The conversations I have seen related to this dramatic change in the CC/MCC arena have ranged in tone from doubtfulness to almost paranoia that the hospital’s finances will be devastated with marked reductions in reimbursement. No doubt, hospitals will be negatively impacted by the magnitude of 1,148 CCs potentially being relegated to a non-cc status. A large majority of hospitals today, especially small, unaffiliated community hospitals and hospitals in rural areas that are financially struggling will experience a large hit and negative margins. Undoubtedly, providers will respond to these proposed changes with comments to Medicare refuting them.

It will certainly be interesting to learn what Medicare decides in the final IPPS rule for 2020. In any event, the sheer magnitude of the 1,492 proposed CC/MCC code changes is all the reason necessary for the clinical documentation improvement specialist (CDIS) profession to finally take note of the immediate need to examine the current mission of CDI and enact wholesale dramatic changes to the processes that have served a meaningful purpose over time, yet have reached the end of their shelf life. The profession is at a juncture similar to that of Interstate Brands, the baker of Wonder Breads, which via a series of management blunders and changing consumer tastes for white bread and sugary, high-calorie cakes waned to such a degree that the company filed for bankruptcy twice in less than 10 years and eventually was sold off in piecemeal fashion. While the CDI industry is not fortunately faced with the same dreadful fate, inaction is not an option that CDI can elect and expect to remain viable.

Redesign and Reposition

The main focus of CDI for the past 10 years has been on reimbursement and case-mix index, achieved through what I always have referred to as task-based, reactive, repetitive activities, mostly consisting of queries. Queries have become the hallmark of CDI, replacing what once was a worthwhile endeavor of CDISs to share documentation-related tips and concepts to drive meaningful, sustainable improvement in the documentation on behalf of the patient as well as the physician, along with all relevant healthcare stakeholders. The time is certainly ripe to reposition present-day CDI programs, transitioning from one that is geared towards reimbursement to one steadfastly focused upon achieving quality documentation for all the right reasons, through treatment and engagement of physicians as constituents and colleagues in our quest to best champion the patient. After all, is said and done, the primary beneficiary of solid and effective communication of patient care is the patient, through the delivery of fully informed, coordinated, patient-centered outcomes.

What exactly do I mean when I suggest we should “redesign and reposition” CDI? After all, these terms are expansive and can assume a wide variety of meanings. “Redesign and reposition,” in my viewpoint, entails working with the fundamentals already established, but expanding our breadth and depth of knowledge and skills in best-practice standards and principles of documentation that serves as the underlying basis for our role in CDI.

First, I strongly advocate for creating a visionary mission of CDI that inspires physicians and other ancillary healthcare providers to work together in a unified approach to achieve documentation excellence. But what should a visionary mission of CDI that drives attainable meaningful improvement in clinical documentation looks like? What support systems and processes are necessary to fully execute and fulfill the well-crafted mission of CDI? What additional training and educational knowledge does a fully seasoned CDI professional require to fulfill their mission?

Constructing a Well-Positioned Mission

I have strongly championed the expansion of the depth and breadth of current clinical documentation improvement processes. Complete and accurate clinical documentation serves a multitude of purposes beyond just reimbursement, forming the backbone of patient care and addressing the roles of all relevant healthcare stakeholders directly and indirectly, in the name of always putting the patient first. Take a look at the mission statement I have created in partnership with several health systems that have embraced the concept of expanding their CDI initiatives, in the spirit of achieving true documentation improvement from a holistic perspective:

  • Clinical documentation improvement is defined by the completeness, consistency, organization, and accuracy of the medical record, reflecting the physician’s clinical judgment and medical decision-making.
  • CDI supports positive outcomes in patient care, quality, cost, resource consumption, fee-for-value, net patient revenue, the transformation from denials and appeals to denials avoidance and overall revenue cycle processes.
  • CDI will consistently strive to ensure accurate and complete capture of all clinically relevant compliant diagnoses to the extent possible, accompanied by accurate capture and reflection of the true patient story with sufficient detail and clarity in support of medical necessity.

Within six months of utilizing this mission statement for CDI and redesigning their current CDI program rooted in the query process to one vested in true documentation improvement, physicians were more highly engaged in learning, becoming more proficient in best-practice standards and principles of clinical documentation, and committing to incorporating these best practices into their daily practice of medicine. Case managers and utilization review staff committed to partnering with the CDI team to act as one, delivering a unified message to physicians on the benefits of complete and accurate clinical documentation to the patient, the care team working on behalf of the patient, and the physician. In addition, the team achieved the attainment of quality outcomes with satisfactory patient satisfaction scores.

From a financial perspective, the health systems significantly drove down unnecessary medical necessity denials and DRG downgrades rooted in poor and/or insufficient physician documentation, beginning with the emergency department and history and physical, which are fundamental to the establishment of medical necessity and the assignment of the most clinically appropriate level of care. Driving down denials and DRG downgrades, along with creating a medical record that accurately depicts a clear and consistent patient story, form the basis for net patient revenue integrity, supporting a high-performing revenue cycle. Effective documentation serves as the underpinning for a solid overall revenue cycle, a key element that CDI must support and put into action in current processes beyond CC/MCC capture, particularly in light of the wholesale changes proposed to the CC/MCC landscape.

In conjunction with the creation of a vision of CDI that inspires, the CDI professional must recognize the essentialness of expanding one’s breadth and depth of knowledge of best practices in the documentation that will be instrumental in engaging physicians as willing participants in any documentation improvement initiative. This is accomplished through self-learning, taking advantage of all the great resources on the Internet.

An ideal starting point is to become familiar with the principles of evaluation and management (E&M), not from a billing perspective but from a documentation perspective. Here are two E&M resources to use, integrating key concepts into the daily CDI practice of chart review and identification of opportunities for documentation clarification, aside from clinical indicators synonymous with a diagnosis (E&M Guidelines, 1995 E&M Guidelines).

My philosophy of continual learning is to let the Internet work for you, and not vice versa. Sign up for the CMS U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), and Medicare Administrative Contractor (MAC) listserves and numerous daily e-mail newsletters available for free on the Internet, such as those offered by Modern Healthcare, Becker’s, American Hospital Association (AHA) News, etc., as there are often timely articles related to the documentation and the practice of medicine available. Share your knowledge of best practices with case management and utilization review, serving as real resources to physicians in real time as part of the chart review, level-of-care decision-making, and authorization process.

The Reality of CDI

The CMS IPPS Proposed Rule, with all the changes in the CC/MCC structure, should bring to light the immediate pressing need for the CDI profession to recognize the fact that current processes of CDI, centered around the query process, fall short of what’s needed. The time is now to put all the industry talk that CDI is about quality to work and become a driving force in the quality of care through the quality of documentation. It’s time to push the reset button and point the industry in the right direction with the right mission. We can control our own destiny if we make the appropriate choices. Let’s not forget the patient in the CDI process.


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