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.

The Ideal State of CDI-

Rather than CDI specialists focus primarily upon capture of diagnoses, i.e., CC/MCC, principal diagnosis shift, HAC and PSI clarification, a more effective model of documentation improvement that produces & achieves greater results emphasized and treats the entire record as a communication tool. The ideal state of clinical documentation embraces the concept of the CDI profession collaborating with UR, Case Management, Social Work, Coding, Denials and Appeals, & Physician Advisors, to enhance the quality and completeness of the documentation integral to the healthcare delivery model. Accurate and complete communication of patient care from initial ED presentation to hospitalization, ongoing progression of care while in the hospital through discharge is paramount to the generation of an encompassing medical record that reflects the right care at the right time for the right reason in the right setting with the right medical necessity and value/cost effectiveness construct.

The present-day model of CDI is not best serving the needs of all healthcare stakeholders including the patient, the physician & all relevant roles served by ancillary service providers in support of an efficient high performing healthcare delivery model, not to mention the revenue cycle. The time is ripe to take a real hard look at current CDI processes and recognize the need for change.

Allow me to share notable positive experiences and strong participatory engagement of physicians in true documentation improvement as I work diligently to transform the established traditional CDI program at my facility into one creating a vision that inspires physicians and ancillary healthcare stakeholders to synergistically collaborate in the name of the patient. Formally in an office sending physician queries electronically day in and day out in clarifying and securing diagnoses, the CDI staff are utilizing Workstation on Wheels to review records on the hospital floors concentrating at times when physicians make rounds. The goal is to build and establish a strong working relationship with physicians and residents, demonstrating the knowledgebase and solid understanding of best practice principles and standards of documentation starting with the History and Physical. An effective and complete H & P is fundamental to establishing medical necessity for hospital level of care from a physician and hospital perspective. The History of Present Illness section of the H & P is critical in the establishment of medical necessity-I constantly remind physicians and residents alike that the burden of proof for medical necessity of the physician service is that of the provider. Claims will be denied as medically reasonable and necessary when the person who renders the service fails to document the medical necessity of the service. Often the HPI is nothing more than a recapitulation of past illnesses that are also included in the Past Family Social History of the H & P, duplicate documentation that adds to note bloat and compromises a concise picture of the patient’s clinical acuity and severity of illness. While the CDI team is receiving training and furthering their understanding of what constitutes complete and accurate clinical documentation, I am working closely with residents and physicians and sharing my knowledge and passion for clear, concise, consistent and contextually accurate clinical documentation through regular rounding with physicians, short open door discussions with residents at their regularly scheduled weekly didactic sessions, and multidisciplinary rounds with hospitalists and case managers. As an integral part of the multidisciplinary rounds, CDI attend the meetings, engage in verbal queries with the physicians and interject suggestions for documentation improvement as part of the dialogue process. The CDI specialists in attendance along with myself make it a point to review the documentation with the record prior to the meeting in preparation for a healthy discussion. This discussion extends well beyond diagnoses capture, incorporating discussion of any insufficiencies and oversights in documentation that detract from an accurate and complete account of the patient story including the communication of the clinical facts, context and clinical information relevant to the entire patient story. The latter points further support and complement efforts in securing clinically relevant diagnoses with proper and appropriate specificity reflective of patient acuity. I have witnessed more and more physicians contacting me on their own and request a concurrent review of their medical record documentation while the patient is still hospitalized seeking feedback and direction in insuring a well-structured H & P outlining their clinical judgment and medical decision making in hospitalizing the patient, all necessary for establishment of medical necessity from a physician perspective.

Just the Beginning

I am confident our CDI program is on the right trajectory path to transform itself into one that reflects the requisite structure and processes to affect sustainable improvement in documentation that is measurable, valid and reliable. This is in direct contrast to current Key Performance Indicators reflective of task based transactional reactionary CDI efforts at capturing and reporting diagnoses, something counterproductive and counterintuitive to achieving real documentation improvement. One of our newly established KPIs for CDI is the volume and dollar amount of medical necessity denials, DRG down-codes and clinical validation denials measured monthly, all serving as reliable indicators of the extent and breadth of effective clinical documentation that CDI is achieving through its expanded efforts at achieving documentation excellence. I challenge other CDI leaders to become thought provocative and begin the long journey of transforming their CDI programs not ones that achieve meaningful change in documentation quality, relying less on the band-aid query process that fails to address the root cause of poor documentation, physician’s understanding and appreciation for the value in strong communication of patient care techniques and standards.