Is Your CDI Program Putting You in the Danger Zone?

Time for CDI checkup.

Clinical Documentation Integrity (CDI) programs may be exposing hospitals to unnecessary, costly compliance risks and financial exposure by virtue of their very nature and purpose.

When the primary focus is upon reimbursement in healthcare as an outcome of any initiative, there is always inherent risk. Designed processes of CDI geared towards achieving optimal reimbursement have a strong tendency to promote aggressive practices to ensure positive results and attainment of individual CDI key performance indicators. This phenomenon applies to CDI programs, with these programs deeply entrenched in most hospitals and health systems.

Counterproductive Forces in CDI

Hospitals and health systems are held to a high standard of compliance under the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) model compliance plan for hospitals. The level and degree of compliance spans all aspects of hospital operations, including all elements of the revenue cycle. Let’s focus upon coding and billing, recognizing that one must also include physician documentation in any discussion of coding and billing. Coders are not permitted to assign ICD-10 codes without explicit physician documentation. When there are inconsistencies and/or conflicting information in the record, the coder is required to query the physician, as repeatedly stated in countless coding clinic citations. Now introduce the efforts of CDI specialists in which records are reviewed concurrently with the stated goal of identifying opportunities for “enhancing documentation integrity” through the query process. A query may be issued for a wide variety of reasons including, but not limited to, the following per the Association of Clinical Documentation Integrity Specialists (ACDIS) Guidelines for Achieving a Compliant Query Practice (2019 Update):

Queries may be necessary in (but are not limited to) the following instances: ­

• To support documentation of medical diagnoses or conditions that are clinically evident and meet Uniform Hospital Discharge Data Set requirements but without the corresponding diagnoses or conditions stated ­

• To resolve conflicting documentation between the attending provider and other treating providers (whether diagnostic or procedural) ­

• To clarify the reason for inpatient admission ­

• To seek clarification when it appears a documented diagnosis is not clinically supported ­

•  To establish a diagnostic cause-and-effect relationship between medical conditions ­

• To establish the acuity or specificity of a documented diagnosis to avoid reporting a default or unspecified code ­

• To establish the relevance of a condition documented as a “history of” to determine if the condition is active and not resolved ­

• To support appropriate Present on Admission (POA) indicator assignment ­

• To clarify if a diagnosis is ruled in or out ­

• To clarify the objective and extent of a procedure

The bottom line in most instances for a CDI-initiated query is some type of impact upon reimbursement, whether it be a capture of a CC/MCC or hospital acquired condition, securing a more specific or alternative principal diagnosis driving reimbursement, and/or reporting of quality measure(s) indirectly impacting reimbursement.

Make no bones about it, CDI is heavily geared towards reimbursement, as opposed to focusing upon achieving true sustainable clinical documentation integrity (as measured by the quality and completeness of physician documentation). The latter can be validated through reliable measures consisting of medical necessity and clinical validation denials, not to mention diagnosis-related group (DRG) and level of care downgrades.

All hospitals are subject to and experiencing greater number of costly self-inflicted payer denials attributable to poor and/or insufficient physician documentation, despite the fact most hospitals have heavily invested in clinical documentation improvement programs. This begs the question of why these costly self-inflicted denials are increasing, despite this major investment in CDI programs. The answer lies in the industry-wide reliance upon current key performance indicators (KPI) that are counterproductive, counterintuitive and pose significant compliance and financial risk for hospitals and health systems. Consider the following KPIs utilized to measure ongoing performance of CDI programs:

• Number of charts reviewed
• Number of queries issued
• Number of queries responded to by the physician
• Physician query agreement rate
• Capture of CC/MCC
• Coder CDI DRG agreement rate
• CC/MCC Capture Rate
• CMI Increase (Gross Number)

CDI-The Reality

I submit to all CDI professionals, revenue cycle professionals, and CFOs that these measures bear no resemblance to valid and reliable measures of actual achievement of true physician documentation. An overwhelming emphasis by CDI programs on these invalid and unreliable measures of performance  geared towards reimbursement outcomes overlooks a critical opportunity to engage in practices and processes of CDI that drive real clinical documentation integrity.

Real clinical documentation integrity consists of far more effective physician documentation that includes the telling and describing of the patient story accompanied by accurate and complete capture of the physician’s clinical judgement, medical decision making, and thought processes. This level and degree of physician documentation achieves “optimal net patient revenue,” less prone to compliance and financial risk or exposure from payers and the vast array of Medicare contractors charged with protecting the Medicare Trust Fund.

Current KPIs drive CDI efforts consisting of task-based activities, representing mere check off lists repeated day in and day out. Fundamental to achieving sustainable measurable clinical documentation integrity is devoting resources, energies, and processes that allow for working with physicians as mentors, guides, and facilitators in achievement of real documentation integrity.

A reasonable starting point is partnering with physicians to enhance their documentation and communication of patient care in the history and physical to the extent accurate reporting and reflecting of the medical necessity for hospital level of care and need for continued stay within the hospital is met. Physicians determine medical necessity for hospital level of care through their documentation within the history and physical within the history of present illness and impression/plan of care.

My colleague Dr. John Zelem puts it very eloquently and succinctly when he says, “Without medical necessity, there simply is no need for CDI; CDI becomes irrelevant.” Lack of medical necessity established by physicians through their documentation and communication of patient care is inarguably a reimbursement and compliance issue under the Medicate Targeted Probe and Educate initiative. An aberrant pattern of too many short stay admissions compared to hospital peers can certainly lead to a focused review by any Medicare Administrative Contractors, something no hospital compliance officer or CFO wants or desires.

The CDI profession with more documentation integrity-aligned processes, migrating away with the query process as the mainstay of CDI, can play a significant role in physicians achieving real clinical documentation integrity through ongoing documentation, educational training, and knowledge sharing. On a side note, the CDI profession must embrace that only the physician can achieve recognized clinical documentation integrity with CDI serving as a resource for the physician.

This notion that CDI in and of itself, through the query process, can achieve clinical documentation integrity is a fallacy. Proof is in the following from the CERT Contractor in its Supplemental Data Report for Fee for Service Improper payment report over the last two years: Seventy-nine percent of improper payments within the Acute Care Inpatient Payment MS-DRG category were attributable to Insufficient Documentation or Medical Necessity. Both improper payment categories are in the purvey of the Clinical Documentation Integrity profession. These high level of improper payment categories consistently identified year over year can be unequivocally interpreted to mean the CDI profession is not focusing on what really matters, the achievement of complete and accurate physician documentation supportive of patient care delivery and a high performing revenue cycle. What the CDI profession is accomplishing through its undivided focus upon task-based activities in the name of reimbursement as the main goal is raising of financial and compliance risk, an intended consequence of CDI programs.

Departing Words

I will follow-up in my next article with specific examples of compliance and financial risk CDI programs exposure our employers using real case studies of payer denials where CDI missed the opportunity to intervene with the physician in securing proactive preemptive denials avoidance documentation. I wish to leave you with the following thought in making a compelling case and argument for the need for total transformation of present CDI processes that have proven ineffective in moving the needle on complete and accurate physician documentation. Please take the following from CMS (Verifying Compliance)

• CMS Contractors Verify Compliance

• CMS employs several review contractors to measure, prevent and identify improper payments. These review contractors manually review claims against the submitted medical documentation to verify the providers’ compliance with Medicare rules and regulations. These review contractors include Palmetto GBA, Comprehensive Error Rate Testing Contractors (CERT), Recovery Auditor Contractor (RAC) and Unified Program Integrity Contractors (UPIC). With so many ‘eyes’ watching, ensure documentation is complete prior to submitting.