Guest Post: Clinical Documentation Improvement: What is your definition?

by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS

CDI as pointed out by AHIMA in their Clinical Documentation Improvement Toolkit is as follows:

• “The purpose of a CDI program is to initiate concurrent and, as appropriate, retrospective reviews of inpatient health records for conflicting, incomplete, or nonspecific provider documentation. These reviews usually occur on the patient care units or can be conducted remotely (via the EHR).
• The goal of these reviews is to identify clinical indicators to ensure that the diagnoses and procedures are supported by ICD-9-CM codes. The method of clarification used by the CDI professional is often written queries in the health record. Verbal and electronic communications are also methods used to make contact with physicians and other providers. These efforts result in an improvement in documentation, coding, reimbursement, and severity of illness (SOI) and risk of mortality (ROM) classifications.”

I recently wrote an article for this forum on clinical documentation improvement discussing my concern with programs which mainly focus on capturing the Almighty “CCs” and “MCCs” and those programs who teach their CDI staff to make sure they receive “credit” for the resulting capture of said CC or MCC for the initiated query.

In fact, I noticed a post on CDI Talk last month that generated quite a stir regarding so-called “credit for queries” that stirred my attention. Specifically, a coding department was receiving “credit” for physicians who positively responded to queries when the CDI staff conducted the front-end work generating the query. What a disheartening feeling to see firsthand evidence of territorial working relationships between the coding department and the clinical documentation improvement specialists.

Instead of devoting precious energy on fighting over who gets “credit” for securing a CC or MCC, let’s set our minds to the real role of CDI—clinician education on the merits of specific, accurate, and detailed documentation to affect positive change in general patterns of physician documentation. In essence, I believe we should focus on successfully engaging the physician to effectively change their documentation behavior patterns.

The Perpetual Treadmill

If you find yourself constantly leaving the same type of clinical clarification query such as the type of congestive heart failure, the stage of chronic kidney disease, the type of pneumonia or if you consistently have to query the physician to “rule in” or “rule out” a diagnosis, consider a different approach. This may signify an opportunity to extol the direct impact of appropriate documentation on the physician’s business and on his or her practice of medicine. It provides CDI programs with an opportunity to explain to the physician that CDI programs aren’t simply about more documentation but more effective, clinically accurate, documentation which ultimately leads to better patient care.

Take the following interaction between a CDI specialist and physician, a verbal query that resulted in a principal diagnosis clarification:

A patient was admitted for acute abdominal pain which waxed and waned but in the last two days had become so intense the patient came to the ER. A provisional diagnosis of acute pancreatitis was documented in the initial history and physical (H&P) on the basis of abnormally elevated liver enzymes. Patient received IV hydration and pain meds over the course of the next three days, abdominal pain subsided to the point patient was stable and discharged on day four.

The CDI specialists appropriately left a query for the physcian to clarify the physician’s clinical thought process of acute pancreatitis but unfortunately there was no response from the physician.  Not surprising in our line of work! This record went to coding after discharge without clarification. So the coding/CDI staff had to “chase down” the physcian for clarification of principal diagnosis after the fact. In so doing, the CDI specialist carries the record around all day long along with a laptop computer hoping to “catch” the physician on rounds and resolve the matter with a verbal query.

At this point, the physician asks: “How many times do I have to document a diagnosis in the record to avoid these queries.” CDI specialist tells the physician that he/she needs to document the diagnosis at least twice to avoid coders questioning the diagnosis, necessitating a query.

Let’s look at this case again to see if we can identify the missed physician education opportunity.

Medicare guidelines provide the general principles of clinical documentation that the physician must adhere to as a standard for Evaluation and Management (E&M) coding and billing. These principles include the following:

The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient’s status.

• The medical record should be complete and legible.
• The documentation of each patient encounter should include:
  • reason for the encounter
  • relevant history
  • physical examination findings
  • prior diagnostic test results
  • assessment
  • clinical impression
  • diagnosis
  • plan for care
  • date
  • legible identity of the observer
• If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
• Past and present diagnoses should be accessible to the treating and/or consulting physician… Appropriate health risk factors should be identified.
• The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.
• The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

Per the Medicare Internet Only Manual Chapter 12, Section 30.6 available here http://www.cms.gov/manuals/downloads/clm104c12.pdf, medical record documentation must meet the following criteria:

• Must be legible;
• Clearly identify patient, date of service, and who performed the service;
• Accurately report all pertinent facts, findings, and observations;
•  Include appropriate diagnosis for the service provided;
• Documentation must have a hand written or an electronic signature. Stamp signatures are not acceptable

Focus on the verbiage that states each patient encounter should include an assessment, clinical impression or diagnosis. I would like to stress that in the inpatient setting an encounter refers to each day’s visit and progress note by the physician.

Thus, in the above conversation with the physcian, the CDI specialist could have capitalized upon the opportunity to educate the physcian on the requirement for daily documentation in the progress note that includes a clinical impression or diagnosis in order to maintain compliance with standards and principles of E&M assignment. By educating the physcian appropriately everyone benefits.

Consider citing third party payer initiatives including the RAC as part of the discussion. Claims often receive a denial based on a diagnosis appearing solely in the H&P and/or discharge summary and not in the progress notes. While there is no specific coding guidelines that states how many times a diagnosis must appear in the record in order to assign a code, obviously the more solid the clinical documentation the less chance of the third party payer having the ammunition to dispute the accuracy of the clinical coding.

Energy Well Spent

Rather searching for “credit for queries” in an attempt to justify the worth of our efforts I suggest we invest our time educating the physician about benefit of complete and accurate clinical documentation to their practice of medicine.

In reality, clinical documentation improvement is a two-way street—a robust record that explains the entire patient encounter helps the physician, the patient, and the hospital. It is our professional duty to bring this concept to bear in our continual efforts to educate physicians and affect positive change in clinical documentation improvement that is meaningful and long lasting.

I have long said and it is my firm belief that we must dispel the ingrained notion that CDI is only about chasing down CCs and MCCs. The continued success of the profession of CDI hinges on our ability to migrate away from episodic, case by case, clinical documentation improvement. Let the work begin.

Editor's note: Krauss, at the time of this article's release, was Executive Director of the Foundation for Physician Documentation Integrity.