CDI, used to clearly communicate the clinical status of a patient, comes with the increased scrutiny of third-party payers and federal oversight agencies.

 EDITOR’S NOTE: Stefani Daniels recently appeared on Talk-Ten-Tuesdays. The following are highlights from her segment on the broadcast.

Hospitals are knee-deep in some radical changes in how and where they’ll be operating, driven largely by the introduction of new delivery systems, new payment methods, new business models, new electronic technologies, and new connectivity tools.

That means that business as usual for case management programs is no longer acceptable – and if you agree that hospital case management is a compilation of services, as the American Case Management Association (ACMA) has stated, then it’s time to closely examine how those services perform in today’s marketplace.

Clinical documentation integrity (CDI) is a case in point, and since it often sits under the case management program umbrella, I am honored to be your guest today. Indeed, I was around when software vendors tapped the more savvy case managers, put them through a six-week coding course, sprinkled some fairy dust, and anointed them as the new clinical documentation improvement specialists.

Back then, the marketplace was looking for opportunities to capture all the appropriate comorbidities and complications (CCS) and major comorbidities and complications (MCCs) related to a case so that they could be coded accurately to establish a correct diagnosis-related group (DRG) for payment. The CDI specialists (CDISs) scanned the entire chart looking for instances of non-specific diagnoses and missing or overlooked diagnoses to ensure that an accurate representation of the patient’s clinical status could be translated into coded data.

But as the marketplace has evolved over the last decade, especially in the area of new payment models, documentation as a means to clearly communicate the clinical status of a patient has become a game-changer in the context of the increased scrutiny of third-party payers and federal oversight agencies. But who is helping the physician keep up with escalating medical necessity demands?

They certainly aren’t getting any education on the topic in medical school, and hospitals do a lackluster job of providing on-site training. Unfortunately, in my experience as a case management consultant, CDI programs have not stepped up to the plate, and CDISs are still slavishly focused on CC/MCC capture.

Because CDI and utilization review (UR) are so often closely aligned, I’ve had the opportunity to work with some great CDISs, and I know they are very aware that documentation as a communication tool to concisely and coherently convey the patient’s clinical status and medical needs is essential (and if done well, will generate diagnoses that are correct and comprehensive and will promote accurate coding). Yet they are often organizationally and operationally distant from the source – the medical staff.

The presence of the electronic medical record (EMR) has created a generation of CDISs who may never see or speak with a physician. Everything is done electronically, and the staff is sometimes centrally hidden in a basement office or off campus. That worked when correct coding was key to optimal payment, but today, correct documentation is of even greater importance, since it influences not only the coding but the medical necessity denials.

Just as so many hospital leaders are still using the popular 1990s discharge planning (DCP) and UR model of case management while their more prescient colleagues recognize that care coordination is the lynchpin of a future value-based payment system and population health marketplace, so too should CDI leaders recognize that complete, accurate, and concise medical documentation is the lynchpin for all points on the revenue cycle.

The goals of the CDI specialist and the UR specialist overlap, but both are dependent on documentation. Is it really efficient to have both specialists reviewing the very same documentation for similar reasons (the CDI to capture CC/MCCs while the UR is looking for documentation that supports medical necessity for hospital level of care)?

The integration of the CDIS role with the UR role at the point of entry seems intuitive to me. Co-located between the emergency department (ED) and admissions office to serve medical staff in the community and the ED, this represents a valuable resource, especially if you’re among the hospitals which are hemorrhaging 835 denial remittances.

Medical necessity depends upon documentation available to the physician “at the time of admission.” What skill set does this new role bring to the physician to guide clinical documentation improvement?

Medicare and other third-party payers expect evidence of complex medical decision-making. Using a template derived from American Health Information Management Association (AHIMA) experts, the CDI/UR specialist can coach the admitting physician to include:

  1. History of present illness (HPI), done in the ED to expedite patient movement. A more complete history and physical (H&P) can be done once patient is in the hospital bed.
  2. An admission treatment plan that includes orders for services and/or treatments that can only be safely provided at hospital level of care.
  3. “Certifying” expectation of the two-midnight rule with a “because clause.”
  4. Risk if the patient is not treated in hospital. For example: “Mrs. S is a 73-year-old female who presented with fever and altered mental status secondary to a UTI. It is expected she will require hospital care spanning two midnights because she has multiple comorbidities, including DMII, chronic systolic CHF, and CKD stage 3. She is at risk for rapid deterioration and will require IV antibiotics, IV fluids, and close monitoring to avoid complications.

Without a concise portrait of the patient documented at the time of admission, the risk of a payment denial escalates. I always suggest reviewing the 835 first-pass payer remittances to get a taste of the hemorrhaging that goes on in many hospitals. Don’t just include the amount of the potential denial, but then add in the back end and rework costs of resubmitting a claim. It’s simply inexcusable, and I don’t understand why chief financial officers (CFOs) continue to ignore the obvious.


Stefani Daniels, MSN, ACM, CMAC

Stefani Daniels is the founder and senior advisor to Phoenix Medical Management, Inc, a boutique consulting firm that specializes entirely on case management and utilization review. Ms. Daniels is a member of the editorial board of Lippincott's Professional Case Management journal and co-author of the popular text The Leader's Guide to Hospital Case Management and The Hospital Guide to Contemporary Utilization Review and a contributing author to the 2nd and 3rd edition of CMSA's Core Curriculum for Case Managers.

You May Also Like

HCCs: The Role of CDI and Risk Scores

HCCs: The Role of CDI and Risk Scores

Predicting coding patterns using the HCC risk scores can be a valuable endeavor. EDITOR’S NOTE: Longtime RACmonitor contributing correspondent Frank Cohen, a senior healthcare analyst,

Read More

Leave a Reply

Your Name(Required)
Your Email(Required)