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There is a three-step process for improving the CDI process, bringing it closer to true clinical documentation integrity.

All hospitals and health systems are facing continuing financial challenges associated with dealing with the COVID-19 pandemic. While news reports note that the Omicron variant is trending downward, there is inarguably no shortage of hospitalized patients with healthcare worker burnout and widespread shortages of qualified healthcare professionals, including nurses, respiratory therapists, and even physicians. The National Hospital Kaufman Hall Flash Report for January 2022 provides real-time financial data that highlights these financial challenges hospitals and health systems are dealing with: (Kaufuman Hall Flash Report).

Adding to these current financial challenges are payers that are still maintaining and expanding their cost-containment, profit-centered initiatives to downgrade hospital level-of-care decisions by physicians to observation, deny care under the auspices of lack of medical necessity, challenge physicians’ clinical judgment and medical decision-making on the basis of clinical validation diagnosis determinations, and lastly, challenge coders’ assignment of ICD-10 diagnosis and procedure codes, with the goal of downgrading MS-RG assignment. One must not overlook payers or their contractors reviewing inpatient stays two to three years after initially paying the claim to claw back monies from the provider, utilizing the above rationale. A physician colleague of mine recently equated the healthcare revenue cycle to a cat-and-mouse game, with the payer controlling the upper hand just because they control the purse strings. What strategies can a hospital or health system consider, mount, and deploy in a concerted attempt to level the playing field with the payers and alleviate roadblocks thrown up by the payer to deny much-needed reimbursement for patient care services rendered?

A Historic Background to CDI
Most hospitals and health systems have invested heavily in clinical documentation integrity (CDI) initiatives, both in the inpatient and outpatient setting, with the goal of optimizing revenue through better physician clinical documentation. Interest in clinical documentation improvement, now known as clinical documentation “integrity” programs, became entrenched, with consulting companies promoting their programs as means of maximizing revenue through capture of additional diagnoses impacting case mix index and reimbursement.

These diagnoses further evolved with the advent of Medicare Severity-Diagnosis Related Groups (MS-DRGs) in 2007, spearheading the focus and capture of complications and comorbidities (CCs) and major CCs (MCCs) that expanded the number of DRGs within each Major Diagnostic Category. What has remained static and constant in most CDI programs is the primary focus upon diagnosis capture and reimbursement, utilizing the CDI query process to clarify and secure diagnoses as well as present-on-admission (POA) indicators, hospital-acquired conditions (HACs), quality-of-care predictors, and core measures, to name just a few.

CDI programs over time have adopted technology being promoted by CDI consulting companies to “enhance efficiencies” utilizing artificial intelligence (AI), natural language processing (NLP), and other rules-based engines to identify those patient charts with the “optimal likelihood” of physician documentation improvement opportunities, i.e., “reimbursement improvement opportunities.” While I fully support hospitals and health systems optimally being reimbursed for patient services provided, the current CDI process places the cart before the horse, and allows the payer to consistently win in the revenue cycle through self-inflicted denials, as I will outline in the next section of this article.

My colleague Jacob Martin, who I work with as a physician champion in CDI, recently suggested that current CDI processes bear a striking resemblance to tee ball, which you may or may not be familiar with: youngsters aspiring to be the next professional baseball players practice hitting the baseball that resting on a stationary tee.

Consider present-day CDI processes, with primary focus upon diagnosis capture impacting reimbursement and quality scores. A major limitation of this narrowly defined scope of practice in CDI is that the outcome of reimbursement is paramount. Reimbursement is the endpoint, with little if any real material improvement in the quality and completeness of physician documentation achieved in the medical record.

Diagnoses captured through the query process, compliantly with relevant clinical indicators cited, are often not supported by the clinical patient story, as reported by the physician in the history and physical, progress notes, and discharge summary. Adding insult to injury is that the record may contain conflicting physician documentation, such as a physical exam with patient signs and symptoms and test results not supporting and/or refuting the physician diagnoses, whether written as a result of a query or not.

What truly is missing in the record is explicit physician documentation, recording the physician’s clinical judgment, medical decision-making, thought processes, and clinical rationale in support of definitive and/or provisional diagnoses. By virtue of continued pervasive insufficiencies in the physician’s documentation, the CDI profession “tees” the ball for the payer to hit out of the park. This same insufficient and/or poor documentation allows the payer to prevail when it comes to level-of-care determinations and current or retrospective medical necessity denials, not to mention clinical validation denials and DRG downgrades.

Even worse, revenue cycle directors, chief financial officers, other C-suite executives, and CDI leadership facilitate and perpetuate the obvious lack of focus upon achieving true clinical documentation integrity through an unrelenting fixation upon current key performance indicators (KPIs) that are nothing more than task-based activities bearing little if any resemblance to true CDI.

All that is needed is to examine the sheer volume of payer denials that inarguably can be traced back to insufficient and/or poor documentation. CDI as a profession contributes to costly rework, delay in payment, avoidable writeoffs, and increased costs to collect through lack of attention and effort at identifying and addressing documentation insufficiencies in a timely and consistent manner. In most cases, CDI does not take an active role in reviewing payer denials, learning what the payer arguments are for said denials, and improving the documentation moving forward, in the interest of continuous quality improvement and denials avoidance.

So, what must the CDI profession change, in moving beyond ineffective CDI processes? First, alleviate the madness of a repetitive, reactional, and transactional query process by investing the time and effort necessary toward educating physicians in an organized, planned fashion.

Step One:
Stop relying primarily upon querying, and start educating. Take the time to uncover what the physicians and other providers really desire in a physician-driven CDI program. Learn what the physicians are requesting in a program that is meant to document and communicate patient care effectively and efficiently, allowing them to work smarter, not harder. Providers as a whole wish to document accurately the first time around, with fewer time-consuming interruptions from CDI and other ancillary care staff, particularly with the pandemic at hand.

Step Two:
The CDI must become more knowledgeable in what represents “clinical documentation integrity.” This means becoming knowledgeable of the standards and best-practice principles of clinical documentation. What are the critical elements of a history & physical, progress notes, and discharge summaries? What are acceptable practices in copying and pasting, also known as carry-forward, with rampant practices seen today that contribute to “note bloat” and inconsistencies in documentation that payers use to their advantage in denials?

Step Three:
Lastly, CDI must be committed to incorporating an approach that embraces the concept of proactive denials avoidance as the fundamental mission. Processes of CDI that support this mission will engage physicians, benefit the patient and all other healthcare stakeholders, and equally as important, align with a high-performing revenue cycle with optimal reimbursement and less second-guessing from third-party payers.

There is no time like the present to start on the path of CDI transformation. We owe it to our patients, our physicians, and the financial health of our organizations.

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