Optimization of Documentation- Is This the Right Terminology?

Optimization of documentation, is this the right terminology to be utilizing in a conversation regarding documentation improvement and how do you define “optimization of documentation?” DRG were introduced in 1982 as a prospective payment system to contain and curtail excessive Medicare costs associated with Medicare beneficiary hospitalizations. The advent of the DRG system served as a primer for DRG Optimization consulting companies that sprung up like dandelions in the spring, popping up everywhere. These organizations utilized techniques of documentation and coding, often manipulating the clinical truth of documentation in the record to optimize the DRG and thus reimbursement. As the government and its contractors clamped down on illegitimate hospital gains from documentation excesses rooted in DRG maximization, implementing more strict guidelines and regulations governing documentation, coding and billing, attrition took its toll on these companies with many not surviving. The firms still standing evolved into legitimate entities offering clinical documentation improvement services with new firms throwing their hat into the ring recognizing the opportunity to provide a valuable service while earning a reasonable profit. As time progressed the clinical documentation improvement industry and the entire suite of firms servicing and supporting CDI activities have metamorphosed into a mindset of “clinical documentation optimization” driving fundamental structural processes with optimization of revenue as the ultimate achievable outcome.

I am certainly not philosophically against optimal reimbursement as a matter of business principles and ethics of business, after all healthcare is a business that requires positive cash flow and positive net financial margins to survive. An overreliance on optimization of documentation as a means to an end of optimal reimbursement may not coincide with the good of the patient and the honest communication of patient care. Optimization of documentation taking literally and on face value can lead to downstream problems and potential compliance and other issues and concerns. An unrelenting focus upon optimization of documentation through the clinical documentation improvement specialists query process for CCs & MCCs has the strong tendency to documentation of diagnoses that are ripe for third party payer refutation leading to clinical validation denials as well as very costly MS-DRG down-codes with legitimate loss of hospital revenue. The common denominator in clinical documentation optimization contributing to potential loss of net patient revenue and compliance issues is weak or devoid clinical documentation of the clinical facts, clinical information and context of the case in support of the diagnoses of record used in ICD-10 codes and MS-DRG assignment. A medical record that inadequately tells the patient true story, accurately reflecting and reporting the patient encounter that describes, shows, tells and communicates the care provided and why is open to possible allegations of overcoding even if not done intentionally. Optimal clinical documentation does not necessarily correlate with optimal compliant coding, instead it equates to swinging for a homerun when all that is needed is for the batter to get on first base.

Effective clinical documentation is the preferred terminology that drives clinical documentation improvement initiatives in the name of communication of patient care. How best to define effective clinical documentation? I refer to effective documentation within the context of a baseball field with the pitcher representing the physician and the batter representing the patient. The patient getting to first base represents the admission to the hospital. The quality and completeness of the documentation demonstrating and reporting the patient’s severity of illness, nature of presenting problem, degree and extent of comorbidities playing into the management of the patient’s acute conditions, risk of adverse untoward event and need for close monitoring only available in the hospital setting, all documented, described, showed and told in the Emergency Room documentation and History and Physical, allow the patient to reach first paste. The accuracy and completeness of the progress notes supporting the assessment and plan including acute and chronic conditions under active management and treatment coupled with shown progression of the patient represent the remaining bases while home base represents the discharge summary. Progress notes should adhere to and follow the following characteristics:

• Storytelling that relays the particulars of the patient’s illness with vents sequenced chronologically, along with appropriately inserted clinical commentary and discussion of treatments.
• Factually correct
• Temporally relevant (no future tense, references to procedures already done)
• Concise (no fluff; just a concise statement of the facts)
• Devoid of plagiarism
• Analytic– (reflects thoughtful analysis of patient’s diagnosis, status, and treatment options
• Reflective of collaboration (acknowledges collaboration with house staff, nursing, and other consultants)

Clinical documentation improvement specialists collectively as a profession and individually must remain train to improving the quality, completeness, accuracy and effectiveness of the documentation we are charged with achieving and attaining. Do not get caught up in the web of seeking optimal documentation, optimal documentation has no resemblance to complete and accurate documentation. Optimal documentation equates to reimbursement that may not stand the test of time and certainly does not do justice to enhancing the communication of fully informed coordinated care that truly benefits the patient and the physician. I challenge all clinical documentation improvement specialists to take a hard look at what they are accomplishing in their regular daily chart reviews and ask whether documentation is measurably improving. I am confidence you will come to the same conclusion as I have for years.