Tip: Think beyond inpatients when conducting medical record reviews

Consider new Noridian observation vs. inpatient flowchart

CDI specialists should review the overall quality of medical record documentation from the day a patient comes into the ER—regardless of whether that patient ultimately ends up in observation, as an inpatient, or elsewhere.

“Quality of care is not segregated into buckets,” says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI an Independent Revenue Cycle Consultant from Madison, WI and a member of the ACDIS advisory board.

CDI specialists often focus exclusively on inpatient admissions and exclude other reviews due to lack of opportunity to “move the DRG.” Some CDI programs have a rule of thumb of waiting 24-48 hours after admission before reviewing the chart, in order to allow sufficient time for clinical staff to perform a review of studies and workup.

But Krauss says CDI specialists looking to stay on the cutting edge of regulatory trends should rethink this mindset. Quality of documentation includes the entire universe of documentation in the chart, whether that’s observation, inpatient, ambulatory care, and even areas like home health and physical therapy.

“It doesn’t matter where it is, or how it’s paid. It’s how it’s documented,” Krauss says.

Given the increased scrutiny of observation services, records for observation patients are a good place to focus additional CDI efforts.

Noridian Administrative Services LLC, a Medicare Part A contractor for 11 states, recently issued this helpful Inpatient vs. Observation flow chart, an invaluable tool for CDI specialists looking to expand their value to their hospitals.

“We (CDI specialists) should have this checklist in our heads when we conduct reviews. If the history of present illness is poor, or there’s no chief complaint, or the physician’s ER documentation is not adequately describing the patient’s acuity, for example, we need to go back to the doctor,” Krauss says. “We should be thinking along these lines.”

Krauss cites the example of a CDI specialist whose work clarifying the documentation results in a shift of principal diagnosis from chest pain to gastroenteritis or costochondritis. His or her work goes for naught if the chart is audited six months later and is either denied due to a lack of medical necessity, or the hospital has to spend significant money making the case that the patient was appropriately admitted.

“The ramifications of just having the diagnosis in the chart without the facts is tremendous—conclusionary statements don’t go a long ways these days,” he says. “I like to use this flowchart as a mindset—we should be emulating the processes described in this flowchart during our reviews. We’re not serving as case managers, who look at what’s in the chart—we’re looking as CDI specialists at what is missing.”

A review of all record types will likely require a change in the mindset of most CDI specialists—and, more challenging, a change in the mindset of administration who have been sold on a certain idea of what a CDI program is (inpatient/DRG focus only). But Krauss says it’s a battle worth waging.

“It’s not about how many records we touch, the quality of documentation is the bottom line. Without that buy-in from administration who pays your salary, it’s hard to change that mentality,” he says.