Guest Post: Expanding the CDI Horizons: Practical Considerations

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

In my last blog titled Identifying Missing CDI Elements by Expanding Our Horizons, I extolled the virtues of identifying patient medical necessity for inpatient hospitalization and the potential vital role CDI specialists play in working with case management (CM) and utilization review (UR)/management staff.

In this blog post I will focus on offering practical considerations to how to integrate our role as change agents into the daily chart review process.

CDI staff and determination of medical necessity

Clinical documentation serves a number of people and purposes such as:

• Appropriate ICD-9 code and MS-DRG assignment
• Clinical outcome studies
• Reporting of risk adjusted severity of illness
• Readmission as part of the proposed Hospital Value Based Purchasing program
• Quality and efficiency care provisions under proposed rules for Accountable Care Organizations

CDI specialists are also frequently asked to help establish medical necessity for patient admission as well as the medical necessity for a patient’s continued stay in the facility. All of these items depend on clear, concise, accurate, and relevant clinical documentation. I suggest that, as a profession, we stand to expand our presence and elevate our stature in the entire process.

First let me reiterate some key points from the first blog post. The majority of hospitals use some type of commercially available screening criteria (such as Milliman and Interqual) as part of the patient status decision-making process (inpatient versus outpatient verses observation status).  This screening criterion is only one of several considerations as evidenced by the following guidance that appears in the Medicare Program Integrity Manual, Section 6.5.2 as well as the Medicare Benefit Policy Manual, Section 1.10. (Please take a moment to re-read the excerpt from the manual in that earlier post. ) I also want to call your attention to the following statement also contained in the Medicare Benefit Policy Manual on page 7.

“The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient’s medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital’s by-laws and admissions policies, and the relative appropriateness of treatment in each setting.”

While physicians are charged with the complex (and arguably oft considered arbitrary) task of determining patient status, they do not necessarily practice sound documentation patterns to reflect the factors that would support their clinical judgment for a given admission. Too often the result is a claim denial from a Medicare Administrative Contractor, RAC, or CERT. For proof, look no further than the following denial from HighMark Medicare Services:

Medically Unnecessary Service: The beneficiary presented with symptoms of GI upset and atypical chest pain with primary concern being atypical chest pain, rule out AMI. The atypical presentation and the categorization of low risk by the admitting physician would allow for this beneficiary to be evaluated and assessed in hospital observation which can be any designated area of the hospital facility. Inpatient admission is not reasonable and necessary.

In the most recent fourth quarter PEPPER, the number one MS-DRG was chest pain. Chest pain topped the list (as is customarily the case) with a reported 71,604 one-day stays out of a total 159,429 discharges, accounting for 44.91% of all MS-DRG 313 discharges. Naturally, inpatient admission criteria and documentation for chest pain is an area of intense focus by Medicare contractors. Often these cases are denied and stand little chance of successful appeal given the insufficient documentation of the physicians ‘clinical concerns and thought processes.

Case Study-Chest Pain

Let’s take a look at a typical example of physician documentation associated with inpatient admission for chest pain:

• Chief Complaint: Chest pain
• History of Present Illness: This is a 65-year-old male who presented to the emergency room (ER) early this morning complaining of chest pain. He describes the chest pain as waxing and waning. Chest pain resolved in ER. No present complaints of chest pain at the moment.
• Past Family/Social History: Eye surgery, Lisinopril at home, non-smoker, lives with wife in town, father had leukemia and died at age 70.
• Clinical Assessment: Chest pain, rule out acute coronary syndrome, possible unstable angina. Initiate R/O MI protocol.
• Plan: See orders

Admittedly, I left out other portions of the history and physical (H&P), based on the information here, however, we can conclude that the patient’s signs and symptoms associated with the chest pain, not to mention the physician’s thought processes for hospitalization are not adequately delineated in the record. The end result is a potential medical necessity denial that may have been avoided with more robust CDI program clearly outlining the “circumstances of admission.”

Contrast the above documentation with the following actual case that withstood a RAC review:

• Chief Complaint: Weakness, chest pain, and weight loss
• History of Present Illness: This is a 74 year-old-male who was admitted to the hospital through the ER. The patient came to the ER complaining of pain, intermittent, waxing and waning, rated on a pain scale of 9 out of 10. Patient describes the pain as in the left-side chest wall area, radiating to the left upper arm for almost two days off and on. This was a bad chest pain when presented to the ER. He indicates some shortness of breath on exertion and recent weight loss, almost 6-8 pounds over the last two months. The patient also indicated that he been having some heart-burn like symptoms, and he started Prevacid but did not check with his physician to follow-up. Patient denied any obvious rectal bleeding or hematemesis. Before arrival, he took a 325 mg aspirin. He denied any fainting or near syncope. In the ER, he continued to complain of vague chest pain and his breathing was rapid with a respiratory rate of 24, in obvious pain and distress, uncomfortable as compared to how I know him from previous visits in the office. There was no improvement in the ER after nitro and morphine.
• Past Family Social History: MI X2, CABG X2, stroke, hypertension, hyperlipidema, diabetes, overweight, smoker, lives at home with his wife of 25 years, family history of MI in father, diabetes in mother, brother who just passed way at 59 with massive heart attack.

Clinical Assessment:

1. Chest pain, concern for MI in a patient with known risk factors of hypertension, male over 70 years of age, strong family history of early MI, diabetes and hyperlipidemia and previous conditions. New finding of anemia is worrisome. Further close monitoring and workup required. EKG shows some ST changes, depression in V4, V5 which indicates ischemia. Lipid profile ordered, a 2D echo ordered, possible needs for cardiac cath. No additional aspirin or anticoagulation ordered until we rule out any active GI beeding since his hemoglobin was 7.5 on admission. His first troponin was negative. He needs two more troponins every eight hours to rule out MI.
2. Fatigue and weakness secondary to anemia. Anemia secondary to possible GI bleed and/or bone marrow suppression, the patient received one unit in the ER. Second unit ordered.
3. Weight loss. May be related to an intestinal lesion that needs to be ruled out.
4. History of GERD with current anemia. The patient does have a history of GERD. He started himself on Prevacid before. He never had any endoscopy or evaluation by GI, will obtain GI evaluation. Will start him on Nexium 40 mg IV every 12 hours. Guaiac ordered and will monitor hemoglobin daily. CT scan of his abdomen and pelvis also ordered. The patient needs to be evaluated for any colon pathology as lung masses.
5. Intermittent shortness of breath. Could be related to the possible MI and anemia which is clinically significant.

Obviously the detail of this documentation illustrates the need for an inpatient admission. In addition, given the nature of the severity of signs and symptoms and the listing of possible diagnoses including plan of care, the physician is substantiating the fact that the workup will likely require more than 24 hours. Remember what the Medicare Benefit Policy Manual says:

“Physicians should use a 24-hour period as a benchmark, i.e., they should order admission for patients who are expected to need hospital care for 24 hours or more, and treat other patients on an outpatient basis…”

Only information gathered by the physician at the time he/she wrote the order for the inpatient admission can be used by Medicare contractors to determine the appropriateness of the admission.

That is why it is so important for the physician to take the time to accurately depict the patient’s clinical acuity, clinical risk factors, provisional diagnoses, and clinical rationale and judgment.

Expanding the CDI program’s Horizon

CDI specialists can incorporate elements of patient severity of signs/symptoms, current patient risk factors and inclusion of provisional diagnoses into our regular chart reviews. As you review the H&P and the ER report, ask yourself whether the record unequivocally shows a truly “sick” patient as opposed to “telling the reader” indirectly how sick the patient is.

Does the documentation clearly describe as opposed to generalizing the patient’s acuity? This complements our role in clarifying possible clinical entities or disease processes. Furthermore, it increases our opportunity to collaborate with the CM and UR staff to affect positive change in physician documentation to the benefit of all.

The key to expanding our horizons in the profession of CDI is to recognize the needs of a variety of stakeholders. Let the efforts begin.

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