Proper documentation is indeed critical to our modern healthcare system. The accuracy and completeness of clinical documentation that translates into ICD-10 codes utilized in many distinct roles including quality and outcomes reporting, measures of efficiencies and effectiveness of care, and calculation and determination of value is critical to the entire healthcare delivery model. Clinical documentation improvement programs are purported to “improve” the

Palmetto GBA just this week posted on its website an article titled Hospital Readmission Without Septicema discussing the CMS Hospital Readmission Reduction Program. pointing out the cost of unplanned readmissions is $15 to $20 billion annually. Interesting enough the following statements in the article run contrary to findings of a study published in January’s Health Affairs

What many CFOs are being told: “Clinical validation denials and DRG downgrades are the result of egregious, overaggressive payers who ignore official coding guidelines and arbitrarily challenge diagnoses like sepsis, acute respiratory failure, and metabolic encephalopathy.”

Any clinical documentation integrity initiative must embrace the concept of proactivity versus reactivity, rejecting the reactive tendency of complacency and content. Proactivity facilitates and supports achievement of measurable meaningful improvement in physician documentation that best serve’s the patient’s and all relevant healthcare stakeholder’s needs for accurate and complete communication of patient care. Referring to proactivity, I subscribe to

Just like a roadmap or if you use a map direction app such as MapQuest or Waze, one needs a start and end point. The same principle or concept applies to the medical record. There is a definite starting and ending point for a medical record, whether inpatient, observation, office visit, or ED to name just a few settings. Let’s focus upon hospitalization…More than half of patients are admitted to the hospital from the ED so that for all intents and purposes is the starting point.

CDI programs have strong potential to significantly raise compliance risks for the hospital or health system in which the program operates. Compliance departments strive to minimize and alleviate the numerous risks associated with the myriad of components associated with and fundamental to the delivery of healthcare. Clinical documentation improvement initiatives can work in tandem, align and collaborate with the compliance department’s goals and objectives,

CDI’s present-day Key Performance Indicators centered upon reimbursement do not truly reflect a meaningful account of performance in impacting the quality, completeness and effectiveness of medical record documentation. Common KPIs include number of physician queries left, number of queries responded to by the physician, number of queries responded to by the physician that captured a CC or MCC, number of queries responded to by the physician that impacted severity of illness/risk of mortality number of charts opened and reviewed per day, etc.

Listen to Glenn cover various points in the CDI arena. You can check out the website this podcast is featured on here.

A major challenge of current clinical documentation improvement processes is the undivided focus upon reimbursement as the primary outcome, something undisputable with a clear review of present day Key Performance Indicators. The expression and reporting of the clinical truth in the record beginning with the Emergency Room Documentation, transitioning into the H & P and continuing with the consultant reports and progress notes culminating in the discharge summary

The Ideal State of CDI- Collaborating Synergistically With All Other Ancillary Healthcare Roles to Achieve Real Meaningful Improvement in the Communication of Patient Care. Let’s Not Forget the Patient in any CDI Initiative. Reimbursement is a byproduct measure of documentation improvement that is sustainable over time. Rather than CDI specialists focus primarily upon capture of diagnoses, i.e., CC/MCC, principal diagnosis shift, HAC and PSI clarification