Tip: Stay on the right CDI track by querying when appropriate

March 4, 2010

CDI specialists are charged with reviewing concurrent medical records on the hospital floor and clarifying clinical documentation when appropriate. I emphasis the term “appropriate”because there hardly seems to be a time when the opportunity for a clinical query does not exist.

There are instances when a clinical query is definitely appropriate, instances when a clinical query may be appropriate, and instances when a clinical query is not appropriate. More on this in a minute.

I want to call your attention to a recent article entitled Back to Basics-Documentation 101authored by Trailblazer Health, a Medicare Administrative Contractor. The article outlines the basics of documentation providers tend not to follow, items which thereby contribute to an alarming number of claims billed in error.

Key points to the article of relevance to CDI specialists are as follows:

Six distinct items comprise a large part of the information Medicare requires in order to deem a service correct and payable. Documenting them thoughtfully is easy. The six items are:
- Who aretheperforming, supervising, and referring practitioners
- What (and How Many) services and quantities of services were performed
- Where did the patient receive the treatment, what was the place of service
- When was theate of service
- Why did the patient receive treatment, what was the medical necessity and diagnosis
The fundamental underpinnings for documenting and reporting services to Medicare are that every item of information reported on the claim (electronic or paper) must be true and accurate, and it must be reflected in the patient’s medical record.

What does this have to do with CDI?

The answer lies in the element of “Medical necessity and diagnosis.” CDI specialists must help to support and substantiate medical necessity for inpatient admissions and continued hospitalization.

The article goes on to state that, with very few exceptions, the original law that created Medicare requires that all services for which Medicare reimbursement is sought must be medically reasonable and necessary. For a service to be medically necessary, it must be all of the following:

Appropriate in duration and frequency
Meets but does not exceed the patient’s medical need
Provided in accordance with accepted standards of medical practice
Not experimental or investigational
Performed by qualified personnel in an appropriate setting

Finally, the most important part of the article directly relates to CDI specialists:

“Medicare requires the informational content [the facts about the patient’s condition] in the medical record to demonstrate all of the above. The facts, not just conclusion statements, must demonstrate that the patient has the diagnosis reported on the claim and that the patient’s condition fulfills all coverage provisions of all Medicare rules and policies.”

The fact of the matter is that CDI specialists must remain cognizant of the concept of medical necessity in their efforts to affect positive change in physician clinical documentation, from a daily documentation, and physician education, standpoint.

Seeking physician clarification and documentation particularly on “possible,” or “suspected” clinical conditions is a dangerous practice and precedent, given the notion of medical necessity and the clear-cut statement made in the article and worth repeating: “The facts, not just conclusionary statements, must demonstrate that the patient has the diagnosis reported on the claim.” (Emphasis added.)

Putting this all in proper perspective

The majority of us are fully aware of the struggles case managers/utilization review staff face in working with physicians to determine and demonstrate medical necessity for inpatient admission versus observation status as patients cross the threshold of the emergency room. Our role as CDI specialists is to work with physicians and help report their practice of medicine through techniques of specific, accurate, and detailed clinical (SAD) documentation. SAD documentation does not necessarily require more documentation, just more effective documentation.

When seeking clinical clarification in the record, we must not deviate from our clinical knowledge and acumen in inquiring about the possibility of a particular disease process when the clinical indicators do not fully support the diagnosis.

Becoming too aggressive in seeking documentation for specific disease processes such as acute renal failure, sepsis, or acute respiratory failure will certainly play into the hands of Recovery Audit Contractors if the medical record is reviewed and lacks clinical evidence of these clinical entities. On the other hand, lack of the factual support for a diagnosis in the record can affect the physician through allegations of providing medically unnecessary evaluation and management services that are inappropriate in duration or frequency or exceed the patient’s medical need.

The bottom line is: “Do your homework before seeking clinical clarification.” Tread lightly while moving forward in improving clinical documentation. And be sure to keep the clinical analysis in clinical documentation improvement efforts.

Editor’s note: This tip was written by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, independent CDI specialist and reimbursement consultant.

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Physician Queries