CDI Fundamentals

Clinical documentation integrity programs have evolved over time with its expansion of duties and responsibilities beyond CC/MCC diagnosis capture. The profession has expanded its reach into quality measures such as Hospital Acquired Conditions, Patient Safety Indicators, Core Measures, and other documentation driven reportable measures of care. Fundamental to operational performance of any clinical documentation integrity program is enhancing the physician’s communication of patient care through documentation reflective of the patient’s clinical picture, clinical facts, clinical information, and need for hospital level of care. Simply put, it is telling the patient’s story. Improving the degree of completeness and accuracy of the physician’s documentation requires a holistic point of view and mindset on the part of the clinical documentation integrity specialist, not just clicking off CC’s and MCC’s. Partnering with Case Management, Utilization Review and Physician Advisors is essential to achieving optimal physician documentation as each of these discipline’s ability to perform their duties and responsibilities is directly dependent upon the quality of the medical record content. Consistent achievement of complete and accurate physician documentation that is clear, concise, consistent, contextually correct and consensus driven is the hallmark of any clinical documentation integrity professional.

Solid Starting Point

All payers including Medicare require a clear and accurate (establishment) description of the acuity of the presentation (of) for medical necessity justifying all services ordered and/or provided to beneficiaries. Complete and accurate physician documentation must unequivocally establish the physician’s decision for hospitalization regardless of the level of care, inpatient versus observation. This must be the starting point for the clinical documentation integrity specialists. Review of physician documentation for the assessment of the patient’s severity of signs and symptoms, risk of adverse/untoward event and the clinical workup that only can be safely provided and carried out in a hospital inpatient setting requires a distinctly different and unique approach to chart review that extends beyond the traditional approach to CDI. This mindset requires a different lens through which an encompassing chart review is performed. Today’s CDI model is predicated upon retrospectively reviewing records, identifying clinical clues and clinical indicators as well as diagnostic workup and treatment warranting clarification or increased specificity of diagnosis, culminating in the issuing of a physician query. A much more efficient, efficacious, and far more effective CDI model entails the clinical documentation integrity specialists reviewing records proactively, identifying real opportunities for true meaningful measurable improvement in physician documentation beyond mere diagnosis capture or clarification. Our role as a CDI professional is to guide the physician in achieving solid physician documentation to the extent the patient story is sufficiently told. The clinical record should include the patient’s story in as much detail as is required to retell the story ACP Position Statement-Clinical Documentation in the 21st Century

A holistic approach to chart review requires three key components:

• Knowledge, understanding and practical application of best practice standards and principles of physician documentation that conveys the patient’s clinical picture, clinical story, clinical information, and clinical facts of the case, including treatment
• Ability to identify physician documentation deficiencies leading to missing clinical information and/or inconsistencies in the documentation that detract from the establishment of medical necessity necessitating an inpatient level of care
• Confidence and ability to address identified physician documentation deficiencies and/or inconsistencies that detract from clearly establishing and supporting the hospitalization. The CDI professional must have the skill sets, knowledge, core competencies, and sureness in best practice standards and principles of documentation to engage the physician as a willing participant in learning about and becoming more proficient in clinical documentation excellence.

Stay tuned for my next blog where I will share tips and ideas for conducting a thorough chart review, identifying common physician documentation deficiencies, and addressing with the physician. This must be done in a proactive collegial fashion in the interest of proactive preemptive denials avoidance. In the interim, if you have any questions or comments related to physician documentation integrity feel free to reach out to me via email- [email protected]