Does Reimbursement Focused Behavior Drive Process Improvement?

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 is paramount to effective communication of patient care. Often the CDI profession references and points to the fact CDI helps tells the patient story, thereby impacting quality, safety, and reimbursement. I fully support the latter as a byproduct of solid effective contextually accurate clinical documentation; however, I question and downplay the effectiveness of CDI truly impacting positive change in quality and safety through the diagnosis query clarification process. Continue reading and you will clearly see my point.

Getting to the Crux of Documentation

A quick read of this article from Urology Times on January 10th highlights the real pitfalls of focusing primarily upon reimbursement, that is overlooking other crucial elements of healthcare whose effectiveness is predicated upon and directly proportional to the accuracy completeness and spatial nature of the clinical documentation throughout the record. The medical record serves as a communication tool for physicians and other healthcare providers with one important function often overlooked by clinical documentation improvement specialists, that of a medico legal document. CDI is so preoccupied with securing diagnoses as monitored, measured and reported by Key Performance Indicators centered on reimbursement that quite frankly we miss an opportunity to devote sufficient energies in effectively communicating the patient’s care. Medio-legal documentation standards encompass and incorporate a higher level and degree of accountability for physicians to adhere to and master, exercising solid documentation principles extending far beyond diagnoses reporting that CDI emphasizes and hones in on in every chart review. The Doctor’s Company, a physician malpractice insurance company, provides practical useful medical record documentation principles and standards to alleviate and minimize medico-legal compliance risk. I am sharing two links to pertinent documentation related articles that are must reads for all clinical documentation improvement specialists.

Faintest Ink

and Accurate Medical Record Documentation

Now let’s return to the Urology Times Article titled How Incidental Radiology Findings Can Lead to Malpractice Litigation.

The gist of the article is a 60-year-old male patient presented to a local Emergency Room with complaints of abdominal pain radiating to the chest, and dysuria. Cardiology workup was negative resorting to surgery and urology consultations. Patient was prescribed antibiotics for a UTI and as part of the surgery workup patient was admitted and underwent a laparoscopic cholecystectomy. Fast forward 30 months, patient undergoes a routine physical exam and of note is found to have a palpable firm abdominal mass. Ultrasound performed demonstrates a large right kidney mass that nearly doubled in size when compared to the initial ultrasound performed in the Emergency Room 30 months earlier. What was an incidental finding initially that seemed to fall through the cracks in the index Emergency Room visit progressed to a metastatic perinephric leiomyosarcoma, which the patient eventually succumbed to.

Takeaway Message for CDI

In a recent review of cases for purposes of assessing the quality of clinical documentation in records previously reviewed by clinical documentation improvement specialists I uncovered countless cases of insufficient, poor and/or conflicting documentation throughout the record. Similar to this case, I observed records where incidental radiology findings where the clinical significance was not delineated anywhere in the progress notes. The CDI professional likely saw the results of the report as part of his/her regular record review, yet did not query as the finding was not going to impact reimbursement as a CC/MCC. While we cannot be the sole entity attempting to improve clinical documentation effectiveness as a profession we can certainly make meaningful measurable inroads in documentation integrity through promoting, advocating for and instilling within our vision of CDI the notion that opportunities for improvement in documentation extend well beyond diagnosis securement that impact reimbursement. As the article pointed out, does the facility have a policy to address communication of incidental findings to the ordering physician and other physicians who have an express need to know. CDI as a profession must step to the plate and engage in a proactive participatory approach to documentation improvement working with physicians as business associates collaborating to achieve policies, procedures and reasonable standards governing clinical documentation. To ignore documentation improvement opportunities solely on the basis they don’t impact reimbursement does not do justice and best serve the patient, the physician, the medical community and the potential medico-legal ramifications of poor documentation. We are in a new year, let’s initiate a movement to migrate away from strictly reimbursement focused documentation improvement efforts to one that incorporates and supports communication of fully informed coordinated care. Today’s status quo is simply something we should not be satisfied with as CDI professionals.