Integrity or improvement? In too many programs there is very little improvement or integrity achieved within the medical record aside from enhanced capture of diagnoses potentially impacting reimbursement.

Most Clinical Documentation Integrity (CDI) programs are mislabeled and misidentified in the present format. Integrity is defined as the quality or state of being complete or undivided per Merriam-Webster.

A few years back the association representing the Clinical Documentation Improvement Specialist’s community elected to replace the “Improvement” part of the name to “Integrity”, now referred to as Clinical Documentation Integrity Specialists. The other association representing other Clinical Documentation Improvement Specialists followed suit and changed the name to reflect Integrity.

Why the name change?

Well, the rationale included the thought that Integrity better represents and reflects the goals, objectives, and mission of the profession to enhance the integrity of the medical record. Unfortunately, the CDI profession is not living up to and markedly missing the mark in achieving clinical documentation integrity within the record. I will touch base on the reasoning and rationale for my sentiment for present day processes of CDI that in too many instances unwittingly generate even more costly self-inflicted payer denials.

Reimbursement vs. Integrity

The medical record serves first and foremost as a communication tool for physicians to record their findings, observations, thoughts, and clinical management of the patient with capture and reflection of the physician’s clinical judgment, medical decision making and thought processes. In the words of an attorney from a medico-legal perspective, the following describes the purposes of the medical record:

• The primary purpose of a medical record is to provide a complete and accurate description of the patient’s medical history. This includes medical conditions, diagnoses, the care, and treatment you provide, and results of such treatments. A well-documented medical record reflects all clinically relevant aspects of the patient’s health and serves as an effective communication vehicle. (Medical Record Documentation)

Let’s look at current CDI processes that focus primarily upon outcomes of reimbursement through CC/MCC capture and Case Mix Increase facilitated by the query process. Whenever an outcome of any initiative is revenue driven without concomitant focus and intent upon improving actual processes contributing to the endpoint, the achieved outcomes are generally either short lived, less than stellar or detrimental in nature. An analogy is when experiences a flat tire in most of today’s modern vehicles. There is either a “temporary” spare tire, fix a flat kit, or the car is equipped with “run flat” tires. In any case, the fix is designed and intended to be temporary with the driver required to repair the tire in question or purchase a new tire. Now, let’s examine and take a hard look at present day CDI processes consisting of the query process, generating queries to physicians for purposes of solidifying secondary diagnoses, i.e., CC/MCC, or principal diagnoses that directly impact reimbursement. Additional areas commonly queried relate to HCCs, core measures, patient safety indicators, present on admission indicators to name just a few. The point here is that too often the effort and attention of the clinical documentation integrity specialists is upon task-based activities measured by key performance indicators that promote reimbursement outcomes. Present key performance indicators utilized to measure overall CDI performance include but are not limited to number of charts reviewed, number of queries left, query response rate, physician query agreement rate, CC/MCC capture rate, CMI increase, etc. While I fully support hospitals and physicians being reimbursed optimally for care and services provided, this short-term solution consisting of the query process must be considered and recognized as a temporary fix.

Queries produce short term gain at the expense of sustainable long-term performance achievement of complete and accurate physician documentation all the time every time! By virtue of this unrelenting focus upon reimbursement measured within too many CDI programs, the opportunity to effectively address, build upon, and improve the integrity of the medical record and its patient story is overlooked and foregone.

The medical record as a multidisciplinary communication tool is what the CDI profession must recognize and incorporate as the fundamental basis for their mission, vision, and role. In its present format, the CDI profession with present processes and task-based activities do not lend themselves to “integrity.” A more appropriate descriptive title for Clinical Documentation Improvement is “Reimbursement Improvement Program” or “Reimbursement Improvement Program Specialists.”

At the end of the day in too many programs there is very little improvement or integrity achieved within the medical record aside from enhanced capture of diagnoses potentially impacting reimbursement.

Measured CC/MCC Capture Rate and CMI are relative gross numbers that do not necessarily translate into real net patient revenue. Just because a claim is coded and billed with a particular MS-DRG or APR-DRG does not mean the payer will pay the claim as coded and billed. Payers operate under the guise that “It is not so just because the physician said it is so” when it comes to physician documentation of diagnoses that are secured by a query. Payers are becoming more aggressive in their denials for clinical validation and DRG downgrades and while a good number may be egregious in nature, solid complete physician documentation that goes well beyond simple clinical validation is paramount to alleviating any of these costly denials or increasing the ability to rehabilitate these same charts if denied by the payer. Clinical data validation means checking clinical data for correctness and completeness, that the diagnosis being queried, or diagnosis already documented by the physician is clearly supported by the diagnostic information within the medical record. This is where a true CDI professional can shine if one embraces the concept of “Holistic Chart Review.”

A reimbursement specialist pays particular attention and devotes their efforts on linking the diagnosis to clinical findings and clinical results documented within the record. A true CDI professional recognizes both subtle as well as clear cut obvious physician documentation that will likely be a contributing factor or directly causative factor in a payer medical necessity or clinical validation denial or a level of care or DRG downgrade.

Reimbursement Integrity Program Specialists are keen to diagnosis capture and reimbursement while a bona fide Clinical Documentation Integrity Specialists understands, appreciates, and subscribes to the philosophy of treating the medical record as a multidisciplinary communication tool, recognizing the unwavering commitment to patients, physicians, and all other healthcare stakeholder professionals involved in the care of the patient.

The medical record as a communication tool requires a wide-eyed lens team approach to processes that affect positive change in overall physician behavioral patterns of documentation. Diagnosis reporting is just one small but critically important aspect of physician documentation. Improving the physician’s telling, describing, depicting, reflecting, and showing of the patient story, need for hospital level of care, continued hospitalization, clinical progress of the patient, readiness for discharge to post-acute care, and a sufficient discharge summary that meets joint commission requirements at a minimum, is within the scope of the Clinical Documentation Integrity Specialists employing a team approach.

Making the Transition: Clinical Documentation Integrity Specialists

Hospitals and health systems are continuing to experience undue long lasting financial strain as part of the aftereffect of the Covid pandemic. Slowly crawling out from pandemic, hospitals and health systems must strengthen all revenue cycle processes that support a high performing revenue cycle with collection of sustainable net patient revenue.

Fundamental to patient care and the revenue cycle is quality focused complete physician documentation closely approximating the care provided with establishment of medical necessity. The CDI profession must transform present day operational processes to incorporate elements that achieve true meaningful measurable long lasting physician documentation improvement and integrity. Only the physician can achieve and move the needle on clinical documentation excellence.

With the CDI profession becoming the change agent to clinical documentation integrity, working with physician advisors, physicians themselves, case management, utilization review/management, and other healthcare stakeholders, monumental strides can be accomplished in the overall quality and effectiveness of the medical record as a communication tool. This communication tool will best serve the patient and all people involved directly and indirectly in patient care.

A byproduct is preemptive, proactive denials avoidance documentation that is resilient to second guessing by payers resulting in financial recoupment.

The time for CDI transformation is now!