Guest Post: Identifying Missing CDI Elements by Expanding Our Horizons

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

While riding the gondola at Snowbasin ski area last week in Utah, I had the opportunity to converse with a physician (who happened to be riding up the lift with me) regarding the field of CDI. His interpretation of CDI centered around a hospital’s effort at improving its finances on the backs of physicians who were expected to document more and respond to “pesky” queries on a regular basis.

Needless to say, it was an interesting ride up! Fortunately (or unfortunately), the ride up the mountain lasted only 10 minutes, hardly enough time to convince this particular physician of the positive effect CDI programs can have. Those of us working in the field know that CDI specialists play an integral role in the revenue cycle function of hospitals, as I have described in past ACDIS blog posts.  A fundamental role of CDI specialists is to review the record:

1. for inconsistencies in clinical documentation
2. to identify opportunities for increased specificity of documented diagnoses based upon clinical indicators and/or clinical management of the patient, and
3. to solidify and clarify clinical documentation when clinical indicators and/or clinical management of the patient indicate likely clinical conditions being managed yet not documented in the record

Frequently, the success of our efforts in CDI is measured by an increase in a facility’s case-mix, CC/MCC capture rate, number of queries generated, number of queries positively responded to by the physician that impact the case-mix and revenue, and volume of records reviewed. But the discussion on the slopes last week solidified my conviction that our profession too narrowly defines its success on reimbursement for short-term gain while downplaying the “missing elements” of the record that can cause positive change and add value, not only to the hospital’s outcomes and reimbursement but for the physician as well.

The “Missing Elements”

As CDI specialists, we are all too familiar with the initiatives of the Recovery Audit Contractors (RACs) and other CMS contractors, such as the CERT contractors and Medicare Administrative Contractors (MACs), to identify and prevent improper payment to Medicare providers through automated and complex chart reviews. Two primary areas of focus entail identification of coding errors (MS-DRG error assignment) and instances of medical necessity wherein the patient was allegedly treated under the unnecessary patient designation of inpatient versus the more appropriate designation of outpatient.

Consider RAC denials for inpatient admission under the contention of lack of medical necessity. In a recent CMS Special Edition article, SE 1037, CMS acknowledged that some CMS contractors are using screening criteria to analyze medical documentation and make a medical necessity determination on inpatient hospital claims. The article sought to reiterate CMS’s policy on the application of commercially-available screening criteria (Interqual and Millman, etc.). It clarified methods for the contractor’s determination of medical necessity and the role of clinical documentation in the establishment of medical necessity for inpatient admission.

The following points are worth noting:

• CMS does not require that the contractor use specific criteria nor endorse any particular brand of screening guidelines.
• CMS contractors are not required to pay a claim even if screening criteria indicate inpatient admission is appropriate. Conversely, CMS contractors are not required to automatically deny a claim that does not meet the admission guidelines of a screening tool.
• In all cases, in addition to screening instruments, the reviewer shall apply his/her own clinical judgment to make a medical review determination based on the documentation in the medical record.
• CMS considers the use of screening criteria as only one tool that should be used by contractors to assist them in making an inpatient hospital claim determination.

So how does the concept of medical necessity apply to CDI specialists, since most believe this is strictly within the realms of case management (CM) and utilization management (UM)/utilization review? The reality is that CDI specialists have an opportunity to work with the CM and UM teams to ensure the record supports the medical necessity the hospital (and the physician) needs to support and justify inpatient admission.

Effective clinical documentation begins in the emergency room (ER), extends through the history and physical (H&P), progress notes, consultant’s report, ancillary interdisciplinary team providers, and discharge summary. Each of these elements is vital to establish medical necessity. As the CDI specialist works to establish complete documentation throughout the record, he or she also works to reinforce the physician’s clinical judgment regarding the medical necessity of the patient’s treatment.

Under present CMS policy, Medicare requires all services meet strict provisions of medical reasonableness and necessity. For a service to be considered medically necessary, it must be all of the following:

• Appropriate in duration and frequency
• Meets but does not exceed 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

Medicare requires that the informational content—the facts, not just conclusory statements—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.  More on this later. (Read, Back to Basics: Documentation 101, Trailblazer Health, for more information.)

SE 1037 references Chapter 6 of the Medicare Program Integrity Manual, Section 6.5.2 as well as the Medicare Benefit Policy Manual, Chapter 1, Section 10, to assist hospitals regarding inpatient admissions. Take note of the following points from the former reference:

• “Review of the medical record must indicate that inpatient hospital care was medically necessary, reasonable,  and appropriate for the diagnosis and condition of the beneficiary at any time during the stay
• The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis
• The reviewer will consider, in his/her review of the medical record, any pre-existing medical problems or extenuating circumstances that make admission of the beneficiary medically necessary
• Inpatient care, rather than outpatient care, is required only if the beneficiary’s medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting”

The latter reference contains the following relevant points regarding factors the physician should consider when making the decision to admit the patient as an inpatient:

• “The severity of the signs and symptoms exhibited by the patient
• The medical predictability of something adverse happening to the patient
  • The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing
  • The availability of diagnostic procedures at the time when and at the location where the patient presents”

Incorporating Missing Elements into CDI Initiatives

Rather than strictly focusing on clarifying and solidifying clinical documentation in the form of principal diagnosis and secondary diagnoses that impact financial reimbursement (i.e., CCs/MCCs) representative of “conclusory statements” by the physician, CDI staff also need to capture the facts of the case to support medical necessity as outlined above in the Medicare reference manuals.

Our review of the record should help to accurately portray patient acuity and severity of signs and/or symptoms as well as medical predictability of something adverse happening to the patient. In essence, we should be looking beyond physician conclusory statements such as “chest pain rule out MI” and automatically clarifying the clinical etiology of chest pain such as costochondritis, GERD, or anxiety reaction in an attempt to improve financial reimbursement. Although such clarification is an essential part of CDI, we should exclude clarification for other purposes. Our efforts cannot occur within a vacuum.

My next blog will conceptualize how CDI specialists can capitalize on the opportunity to incorporate the missing elements of clinical documentation into our clinical documentation review process through discussion of two case studies. Stay tuned.

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