by Glenn Krauss. Creator and Founder of Core-CDI and Co-Founder of Top Gun Audit School
Published on Jan 13, 2020

I would like to share some thoughts on the current state of affairs concerning the practice of clinical documentation integrity with comments on where the profession is now and what direction the profession should be taking in 2020 to drive real CDI process efficiencies that deliver true clinical document integrity. The profession speaks of clinical documentation integrity yet has only scratched at the surface with its present fundamental task-based activities.

The profession of CDI began its heritage nearly 12 years ago with a mission of improving the capture of diagnoses in the form of CCs and MCCs in the name of patient clinical acuity, associated resource consumption, DRG assignment and reimbursement. Certainly, this is a worthwhile endeavor for hospitals to ensure optimal reimbursement for services rendered, particularly considering the tremendous costs of operating a hospital and delivering high quality care. Labor costs is the largest contributor to operating costs right in front of technology and IT costs such as the electronic health record.

CDI initiatives have continued to evolve over the last five to seven years by embracing and incorporating various software platforms and other technology to enhance CDI process efficiencies. These software platforms employ a wide array of technologies utilizing natural language processing and other machine learning activities to identify medical records with the “most opportunity” for clinical documentation improvement, i.e., the largest opportunity for querying the physician in the interest of attaining an additional CC/MCC diagnosis and additional reimbursement. There is even what is referred to as CAPD- Computer Assisted Physician Documentation, designed to “prompt” or “nudge” the physician to document a diagnosis with appropriate clinical specificity to capture and report a CC/MCC to generate greater reimbursement. This approach to deploying software in the spirit of seeking reimbursement increases equates to an arms race where each hospital is attempting to squeeze as much reimbursement as possible out of every record.  But that approach is problematic on several fronts.

Capturing diagnoses without a concomitant effort at improving the patient's clinical 'story' with associated clinical facts, clinical information and context - including a clear account of the patient care provided and the medical necessity for hospital level of care - simply breeds and perpetuates more and more medical necessity and clinical validation denials as well as DRG and level of care downgrades. Subsequent efforts of the staff to re-bill a claim, prepare and submit paper medical records, collect unpaid claims, appeal the denials and adverse level of care determinations, and the volume of potential write offs for uncollectable revenue, all add up to a significant expenditure of avoidable costs.

Additionally, the focus on current CDI processes, dependent upon task based activities, coupled with sophisticated data mining techniques capable of identifying aberrant patterns of coding promoted by overdocumentation and/or hyperdocumentation, create potential compliance risks that expose the hospital to significant financial recoupments and compliance fines. I refer to the concept of hyperdocumentation as documentation of diagnoses with perhaps clinical validators present though the clinical picture and/or clinical facts do not lend themselves to the diagnoses captured through the query process activity.  I recently encountered a situation where an 18 month pattern of coding and DRG billings captured the attention of the OIG which proceeded to carry out a thorough hospital compliance review that turned out to be quite painful and costly to the hospital with much of the costs expended to defend its coding and billing practices. Lending credibility to CMS’s and OIG’s concern for over-coding, the OIG announced a new Work Plan initiative Assessing Inpatient Hospital Billing for Medicare Beneficiaries further demonstrating the OIGs concern with upcoding, mis-coding or over-coding to increase payment: 

  • OIG will conduct a two-part study to assess inpatient hospital billing. The first part will analyze Medicare claims data to provide landscape information about hospital billing. OIG will determine how inpatient hospital billing has changed over time and describe how inpatient billing varied among hospitals. We will then use the results of this analysis to target certain hospitals or codes for a medical review to determine the extent to which the hospitals billed incorrect codes.

Repositioning CDI- Redesigning & Rebranding

With the new year, I propose that the CDI profession embrace transformation of current CDI processes to promote and achieve real sustainable and measurable improvement in the quality and completeness of physician documentation. In support of this shift, ACDIS and AHIMA endorsed the notion of referring to CDI as Clinical Documentation Integrity, migrating away from Clinical Documentation Improvement. Documentation integrity can only be achieved if the vision and mission of a hospital's CDI program is to affect positive change in overall physician patterns of documentation to ensure the concise and accurate communication of the patients story from the time the patient presents to the Emergency Department, through the entire progression of care and discharge.

This attention to documentation excellence requires a totally new approach to CDI.  Diagnosis capture is no longer the priority of the CDI program. In today's marketplace, CDI specialists require an advanced skill set with core copetency in understanding and appreciation of the standards and principles of clinical documentation that effectively and accurately communicate patient care. Only then will CDI be able to confidently refer to the profession as clinical documentation integrity specialists. I challenge all CDI professionals in 2020 to join me in continued learning, advanced training, and the application of best practice standards governing clinical documentation. To shift the traditional role of the CDI specialist to that of Facilitator of Communication of Patient Care, I remain firmly committed to promoting and advocating the redesign of present CDI processes.

Your comments and suggestions are always welcome. Feel free to reach out to me and check out some of the resources on the Top Gun Audit School  to jump start your efforts at continued learning in CDI.