Guest Post: Draft a holistic approach to CDI program development

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

Clinical documentation improvement (CDI) programs have evolved over the last few years as hospital interest in implementing these programs has grown exponentially. Such interest and evolution seems obvious given the healthcare economic climate and Medicare’s decision in the 2010 IPPS proposed rule to factor in a “behavioral adjustment” for supposed increase in hospital’s case mix absent an increase in patient severity and acuity.

Nevertheless, the field of clinical documentation improvement  is relatively new and continues to evolve with the growth of CDI programs.

The fundamentals of CDI programs consists of physician education on the merits of complete, accurate, and effective clinical documentation that can be translated into the most clinically appropriate ICD-9 codes in support of patient acuity, patient severity and risk of morbidity, mortality, and readmission. Different approaches to affecting positive change in physician patterns of medical record documentation may be used by CDI specialists. Typically, educational sessions, handouts, documentation tip sheets, written clinical queries, verbal queries, and monthly newsletters are used as part of CDI programs for this purpose.

However, one important item to consider in any program is the definition of  “clinical documentation improvement.”  To most, the definition consists of ensuring complete and accurate documentation of clinical diagnoses throughout the record in reflection of patient presentation to the hospital, physician treatment and management of the patient, hospital resource consumption and ultimate MS-DRG assignment.

What is missing in CDI programs is a holistic approach. What do I mean by the “holistic approach?” Holistic documentation improvement entails reviewing physician documentation beginning in the emergency room and continuing with the history and physical (H&P), progress notes, consult notes, and discharge summary to ensure complete, accurate, and effective documentation to complement efforts at capturing all reportable diagnoses associated with an inpatient encounter.

Consider the obtaining the following elements as part of the CDI process:

• Patient’s chief complaint or purpose for visit is clearly documented. 
  • Documentation supports the patient’s perceived needs and addresses his/her perceived expectations.
  • Clinical assessment and/or physical findings are recorded.
  • Working diagnoses are consistent with findings.
  • Clinical assessment and physical are documented and correspond to patient’s chief complaint, purpose for seeking care and/or ongoing care for chronic illnesses.
  • Working diagnoses or medical impressions that logically follow from the clinical assessment and physical examination are recorded.
• Plans of action/treatment is consistent with diagnosis(es).
  • Proposed treatment plans, therapies or other regimens are documented and logically follow previously documented diagnoses and medical impressions.
  • Rationale for treatment decisions appears medically appropriate and substantiated by documentation in the record.
  • Laboratory tests are performed at appropriate intervals.

Each of the elements listed above assist the physician in demonstrating medical necessity for inpatient hospitalization, substantiating the need for initial admission to the hospital and continued stay.

How often do we, as CDI specialists, observe daily physician progress notes that do not incorporate  diagnoses? The physician’s billing of an evaluation and management (E/M) service for each inpatient hospital day stay is predicated upon managing a patient condition or disease process that must be explicitly and concisely documented in order to be in compliance with coding guidelines.

How often do we see skimpy history of present illness documentation in the emergency room note or H&P documentation that makes us wonder why the patient was admitted to the hospital in the first place? Sometimes the documentation is so non-existent it detracts from our ability to leave an effective clinical query.

A more effective approach achieves sustainable results via physician behavior modification. A holistic approach includes:

• reviewing the record for clarification
• obtaining of a complete clinical picture of patient acuity and treatment
• ensuring completeness of physician judgment, medical decision-making and clinical impression in support of medical necessity for hospitalization from both the hospital and physician’s perspective

The sole focus upon solidifying physician diagnostic impressions in a CDI program will not necessarily do justice to the established goals and objectives of clinical documentation improvement, that is noticeable positive change in clinical documentation where the record speaks for itself at the time of discharge and coding.

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