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Queries are simply not enough. 

We all read about companies moving jobs overseas to cut costs and drive operating performance, with greater profits. As a result, hundreds, if not thousands, of employees are displaced, forced to seek alternate employment or potentially take early retirement, if offered by the employer.

This phenomenon can be seen when U.S. auto manufacturers move car and parts assembly operations to Mexico, for example, in an effort to cut labor costs, providing for greater overall profits. Let’s look at the healthcare setting, specifically, hospital operations. According to an article titled “What’s Driving Increased Hospital Cost Concerns” that appeared in a Healthcare Financial Management Association (HFMA) publication in July 2018, sums this up nicely, it was estimated that labor expenses make up roughly half of total operating costs for most hospitals. Putting it another way, for every dollar spent in operations of a hospital, 50 cents is invested in labor costs and employee benefits, including health insurance, the cost of which is far outpacing the rate of inflation.

Clinical documentation integrity (CDI) initiatives are widespread throughout the country, with most hospitals having invested in some type of CDI program. Implementing and operating a CDI program is costly, with salaries and benefits of CDI staff, consulting service expenses, CDI leadership oversight, staff training, and education, encoder and other software needs, and usually, a physician advisor who offers advice and serves as a spokesperson for the program. Even considering the total costs associated with operating CDI programs, labor costs constitute the bulk of expenses. Hospitals have addressed similar labor-intensive costs associated with medical records coding through a dual-pronged approach to cost containment by investing in computer-assisted coding as well as outsourcing coding to low-cost overseas vendors. As a matter of fact, there is a noticeable tradeoff in the quality of coding for accepting lower-cost “production coding.” Every facility about which I have firsthand knowledge that migrated to overseas outsourced coding experienced significantly lower-quality coding, accepting the fact of increased denials, increased rework for rejected claims, and increased costs to collect – all in an effort to “cut labor costs.”

So, what does this have to do with the CDI profession?

When the Status Quo is Your Worst Enemy
I have learned in my long career in the revenue cycle, with a special emphasis upon CDI and coding, that the status quo is your worst enemy. Continually enhancing one’s knowledge and skillsets are fundamental to career advancement and value-add to your organization, especially in times of downsizing, “right-sizing,” and reductions in force in the name of cost-cutting, something quite prevalent in the healthcare industry, as hospitals experience cost growth outpacing revenue growth, particularly with labor costs. A natural business strategy to address expenses outpacing revenue with margin compressions is to reduce costs through labor force reductions – or, in the hospital setting, outsourcing of “back-off administrative” functions such as billing, coding, cash posting, denials management, and collections follow-up. Consider the following recent unfortunate business decision, wherein a CDI department was informed that their positions were being outsourced overseas.

I had the privilege of working with a staff of five very dedicated, competent CDI professionals who were committed to improving clinical documentation, adhering to the traditional model of CDI embracing compliant written and verbal queries. There was a reluctance to deviate from the traditional norms of CDI, with the use of customary, task-based key performance indicators (KPIs), such as the number of charts reviewed, number of queries left, physician query agreement rate, co-morbidity or complication (CC)/major CC (MCC) capture rate, etc. Coupled with this deeply ingrained attitude was management’s decision to favor the traditional counterproductive, counterintuitive query process of CDI, making the invalid assumption that hitting KPI targets with case mix index (CMI) increases represented a reliable measure of CDI performance. These assumptions are predicated upon misinformation promoted and perpetuated by CDI consulting companies as a means of justifying the continued need for their CDI consulting services. On Friday, the hammer dropped on these hardworking, conscientious CDI professionals, who were notified their jobs were being eliminated in the spirit of cost containment.

Can This Happen to You?
The $64,000 question to be considered with this hospital’s CDI outsourcing decision is whether it was a one-off occurrence, or a start to a nationwide trend to outsource CDI overseas, treating CDI as a task-based “back-off” activity that can be carried out more cost-effectively as an outsourced function. No one knows the answer to this important question; however, any decision to outsource CDI should raise concerns for all CDI professionals, especially those who primarily work remotely, basically serving as generators of queries, with little if any direct physician documentation educational activities. Clinical documentation integrity extends well beyond diagnosis capture, culminating in CMI increases, generating supposed enhanced reimbursement.

Consider the following shortfalls in the documentation that can be addressed through properly designed CDI processes that truly impact documentation quality and completeness in the name of patient care and quality medicine. The profession must commit to achieving clinical documentation excellence versus clinical documentation integrity; no one should be content with “integrity” or “improvement.” My parents, in my schooling, always stressed “excellence” in learnings and grade assignments; “improvement” in grades was not acceptable. The same premise must apply to the CDI profession. Consider the following common shortfalls:

  • Reviewing records without incorporating true appreciation, understanding, and application of the clinical facts, clinical information, and context of admission. Not looking for an accurate account of the clinical picture (what did the patient look like, how did the condition manifest, what is wrong with the patient, etc.). Performing these tasks helps frame an understanding of the circumstances of admission, which provides a basis for the establishment of medical necessity, especially the completeness of the patient’s clinical picture displayed in the history of present illness (HPI).
  • Overlooking the establishment of medical necessity through addressing insufficiencies in the HPI with the physician in real-time. There should be a minimum of four elements of any HPI, and there is eight total, as follows: location, quality, severity, duration, modifying factors, context, associated signs and symptoms, and timing. Without at least four elements of HPI, a physician cannot bill an initial evaluation and management (E&M) inpatient hospitalization, using codes 99221-99223.
  • Overlooking inconsistencies in clinical documentation that detract from medical necessity. This would include, for example, a progress note listing language such as “under constitutional physical exam: alert and oriented, in no distress, speaking full sentences,” when the diagnosis in the assessment is “acute hypoxemic respiratory failure” – or the same verbiage as above, with diagnoses of the following in the assessment:
    • Severe lower urinary tract infection, secondary to noncompliance with outpatient medications
    • Acute encephalopathy secondary to No. 1
  • When the physical exam refutes the diagnosis that payers and auditors use as the basis for denying PDx or secondary diagnoses, reducing the reimbursement to a lower-paying DRG by switching the PDX or removing a CC/MCC. The bottom line is that CDI focusing upon task-based activities overlooks the opportunity to enhance the value and completeness in telling the patient story that is fundamental to the establishment of medical necessity for designation of hospital level of care.
  • Overlooking the opportunity to address the shortcomings of the clinical impression/assessment that detract from the patient story. The two-midnight rule is based upon a reasonable need for a stay that will span at least two midnights, based upon documentation of what the physician knew at the time of the decision to hospitalize the patient. This “reasonable need” reporting is predicated upon solid and complete documentation of the physician that appears in the HPI, the constitutional portion of the physical exam, findings in the physical exam, results of testing and workup completed thus far in the ED, and abnormal findings and results, culminating in the assessment, which should include definitive as well as provisional diagnoses. The opportunity to educate physicians on the necessity for an encompassing assessment, including all relevant and provisional diagnoses, is essential to the establishment of medical necessity.
  • Overlooking the opportunity to work with the physician to ensure an accurate clinical impression/assessment that is supported by the HPI, and is in line with the physical exam and other findings and treatments, as documented or appearing in the chart. Clinical rationale and thought processes of the physician, documented within the assessment, are essential in supporting clinical validation of a definitive and/or provisional diagnosis. For example, I saw a denial today for medical necessity for inpatient admission related to a diagnosis of pneumonia. Why? Because the chest X-ray was clear, there was no white count, low-grade temperature, oxygenation reduced a bit (down to 92 percent), lungs noisy in the physical exam, with coarse breath sounds, wheezing, rhonchi, and rales. The payer says there is no pneumonia and no need for an inpatient level of care.
  • When the plan of care is not congruent and reasonable. Every order should be traceable to a definitive or provisional diagnosis, something that is necessary for the case manager to identify rationale and discuss the merits of the need for a specific hospital level of care. Hospital level of care is based upon the patient’s severity of illness, as described in the HPI, results of the physical exam, abnormal results, and findings discussed by the physician in the documentation, as well as thoughts as to diagnoses.

Transforming CDI: Task-Based Versus Role-Based Activities
I have been advocating for “non-traditional” approaches to CDI that address significant shortfalls in physician documentation, beyond diagnosis capture. It is my sincere hope that the outsourcing phenomenon associated with medical records coding does not repeat itself in the CDI arena. CDI, in its present format, lends itself to task-based considerations, predicated upon the task-based query process. Take a close look at current KPIs utilized to measure the performance of CDI programs, all task-based that can be completed off-site, by staff thousands of miles away. The CDI profession must not be content with the status quo, must not continue to support KPIs that perpetuate task-based activities, and must not idly stand by and watch their positions be outsourced. This is an important call to action; only you can control your destiny.


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