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A recent conversation with a fellow clinical documentation integrity (CDI) specialist about the role of the profession as it pertains to enhancing and affecting positive change in communication of patient care by transitioning to a more holistic approach really struck a chord in me – and it made me question whether CDI as a whole needs a wake-up call.

There is certainly pervasive resistance to change in the industry, as I will attest, and furthermore a general comfort level with current processes and lack of true interest in expanding upon present methodologies. Apathy and inability to recognize an expanding vision of CDI breeds staleness, and a potential downward trajectory of the profession.

Clinical Documentation Serving Multiple Purposes

Clinical documentation should serve a multitude of purposes throughout the healthcare delivery model, all centered around communication of patient care. There must be reporting of the right care at the right time for the right reason in the right setting with the right documentation expressing the right clinical judgment and medical decision-making with the right plan of care – this is the hallmark of good communication of patient care. All the ancillary roles of healthcare that function in a supportive capacity to the physician’s clinical management are directly dependent upon the quality and completeness of the medical record. Quality of care, safety, infection control, risk, value-based, cost-effective outcomes based on provision of care, utilization review/utilization management, and case management functions are contingent and influenced by the source documents in the medical record. I have personally experienced the aftermath of common insufficiencies and patterns of poor documentation as a case manager, attempting to obtain authorization of inpatient stays, wherein the account of the clinical scenario, clinical information, and facts of the case was woefully inadequate.

With the advent of the electronic health record, the quality and accuracy of documentation has been degraded by the nature of shortcuts such as of copying and pasting, carry-forwards, dropdown menus, and point-and-clicks. This phenomenon negatively contributes to quality of care.

The Big Word is Out

Medical necessity and “reasonable and necessary” care are a major focus of third-party payors, used as one of many justifications to deny payment for services rendered. While the concept of medical necessity is somewhat nebulous, it certainly is not as difficult as it’s portrayed.

How does a physician best capture medical necessity for all service provisions, whether provided directly or ordered by the physician? The crux of the matter is that effective documentation reflective of clinical judgment and medical decision-making is necessary. Clinical judgment is defined as the physician performing an assessment of a patient’s particular clinical scenario and the initiation of a plan of care congruent with the assessment.

Medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option, which is determined by considering these factors:

  • The number of possible diagnoses and/or the number of management options that must be considered;
  • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and
  • The risk of significant complications, morbidity, and/or mortality, as well as comorbidities associated with the patient’s presenting problem(s), diagnostic procedure(s), and/or the possible management options.

Establishing medical necessity clearly does not require more physician documentation and time on the part of the physician; in fact, on the contrary – it requires less time, with more direction toward effective documentation. Today’s documentation has a tendency to be a hodgepodge of information that often makes no clinical sense (or at the minimum, creates a grave picture of situational awareness).

Gaining a proper perspective on situational awareness can be attained by simply asking a consultant in the hospital about his or her biggest challenge in performing a consult on a patient. Undoubtedly, the response will center upon something like “I have no idea what I am supposed to consult on, as I don’t know what is wrong with the patient” or “I am not sure what the hospitalist who called the consult is thinking, making it difficult for me to provide an informative opinion and recommendations.”

The ability of the physician to accurately report medical necessity for patient care hinges on the physician’s ability to adequately express his or her clinical judgment and medical decision-making that is unique to the patient’s clinical scenario, given that every patient possesses unique care needs. Medical necessity, as I pointed out in a previous article, is determined through a combination of vital factors, including but not limited to the following:

  • Clinical judgment
  • Standards of practice
  • Why the patient needs to be seen (chief complaint)
  • Any acute exacerbations/onsets of medical conditions or injuries
  • The stability/acuity of the patient
  • Multiple medical co-morbidities
  • The management of the patient for a specific date of service (DOS)

Fundamental to reporting these vital factors is clear, concise, consistent, and explicit clinical documentation of the chief complaint, history of present illness, severity of signs and symptoms, and more.

This is where I beg to differ in my recent conversation with the CDI specialist colleague: specifically, regarding our profession’s role in significantly impacting true documentation improvement. A top priority must be achieving optimal value proposition for the hospital’s revenue cycle while ideally serving the patient’s needs.

Case Manager/Utilization versus CDIS

The purveyor of complete, accurate, and effective documentation is the clinical documentation improvement specialist, working in tandem with a vested dedicated physician advisor and case management. Contrary to this viewpoint, the case manager is not solely responsible for impacting positive change in documentation. The case manager’s primary duties and responsibilities are rooted in insuring the movement of the patient along the care continuum in a timely and efficient fashion, coordinating and orchestrating an appropriate discharge with follow-up that best serves post-acute care needs while reducing the incidence of readmission. Within this scope of work is the review of the documentation available and assessment and determination of medical necessity for hospitalization.

Where the CDIS comes into play to complement the case management function is to clarify diagnosis reporting, results of diagnostic workup, and management, including the provision of tests and treatment. Today’s focus upon value-based healthcare delivery models requires a higher level of skill and commitment to manage both the patient’s acute needs as well as chronic healthcare conditions in the hospital and post-acute care settings. Case managers recognize when documentation is insufficient and poor, being only able to work with the documentation that’s readily available. CDISs, by their very nature and training, are experienced in reviewing records and identifying missed opportunities for reporting additional diagnoses or achieving increased clinical specificity.

Our thought processes, skill sets, and core competencies align well with those of case management utilization review/utilization management specialists to produce real, meaningful improvement in documentation that best communicates patient care. CDI specialists should embrace the notion of working in tandem with case management utilization review/management in a unified effort to improve the quality and completeness of documentation throughout the entire patient stay. Diagnosis reporting serves a valuable purpose, and equally important is clinical information, which has an immediate impact upon healthcare delivery.

Data gathering in the form of diagnoses that serve as the basis for outcome measures such as risk of mortality/severity of illness, case mix index, expected versus observed mortality, and physician and hospital profiling are vitally important to successfully competing in a changing healthcare environment wherein emphasis is more greatly focused upon disease prevention and efficient use of increasingly costly healthcare resources. Just the same, what is mandated by the transformational change in healthcare delivery models is a complete and accurate picture of patient care; this by definition requires more than mere reporting of diagnoses. A higher degree of communication of patient care is necessary, consisting of easily synthesized documentation that clearly paints an accurate picture of the patient encounter.

Medical Review Process

The electronic health record serves as a documentation tool, supposedly enhancing efficiencies, though at times seemingly at the expense of quality of the communicated care. A quick look at any inpatient patient encounter highlights the fact that documentation is often not well-organized, consistent, or clearly orchestrated. The result is potentially compromised quality of care, increasing the likelihood of an adverse patient event, inappropriate care, and/or injudicious use of hospital resources. Aside from negatively impacting patient care, poorly organized documentation degrades the synthesis of information outside reviewers use to judge the appropriateness of the physician’s clinical judgment. Let’s look at the Centers for Medicare & Medicaid Services (CMS) Program Integrity Manual, Chapter 3, Section, under the Medical Records Review  Program Integrity Manual:

  • Clinical Review Judgment

Clinical review judgment involves two steps:

  1. The synthesis of all submitted medical record information (e.g. progress notes, diagnostic findings, medications, nursing notes, etc.) to create a longitudinal clinical picture of the patient; and
  2. The application of this clinical picture to the review criteria is to make a reviewer determination on whether the clinical requirements in the relevant policy have been met.
  • Audit contractor clinical review staff shall use clinical review judgment when making medical record review determinations about a claim. Clinical review judgment does not replace poor or inadequate medical records. Clinical review judgement is not a process that these contractors can use to override, supersede, or disregard a policy requirement. Policies include laws, regulations, CMS rulings, manual instructions, and others.

In Summary

Communication of patient care requires a greater degree of precision and detail, outlining in clear fashion the care provided, thereby facilitating the ease in synthesis of clinical information within the record that best tells the real story. Clearly, this necessitates attention to recording of the clinical facts, information, and context of the care provided. CDI as a profession has an undisputable role in fulfilling its duties to impact positive change in documentation quality, recognizing that data-gathering in the form of focusing on diagnoses only is outdated. It is time to recognize accountability for fulfilling the title of our profession: “clinical documentation improvement.” To this end, we must consider our role as one of customer service, serving the needs of the patient and physician in complete, accurate, and effective communication of patient care.


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