Accurate and Complete Documentation Best Aligning and Integrating with the Revenue Cycle

To best align and integrate with the revenue cycle with lasting sustainable impact, clinical documentation improvement programs must embrace and operationalize processes that achieve real measurable improvement in documentation. Rather than focus upon present Key Performance Indicators measuring outcomes consisting of gross patient revenue, high performing CDI programs achieve accurate, precise and complete documentation that effectively communicates the patient care provided and the attained outcomes. CDI programs better and more closely align and integrate with the revenue cycle when the established goals and objectives of program transform and transgress communication centric versus revenue centric fundamentals. Commitment and dedication to communication centric documentation reflecting truthful reporting and reflection of the patient’s clinical information, facts of the clinical scenario, physician’s clinical judgment and medical decision making, supports accurate code assignment translating into appropriate net patient revenue. Don’t confuse and associate documentation improvement with achievement of optimal coding, MS-DRG assignment and gross patient revenue that fails to withstand outside regulatory scrutiny. Instead, focus upon documentation that consistently communicates patient care which will result in the natural byproduct of optimal code, MS-DRG assignment and alignment and integration of the revenue cycle.

Key Steps to Transform CDI from Reimbursement to Communication of Patient Care

• Reject the notion that traditional Key Performance Indicators such as number of queries issued, number of charts reviewed, query response rate, CC/MCC capture rate, case mix increase, etc., are the sole measure(s) of clinical documentation improvement initiatives. Diagnosis capture and reporting in and of itself does not correlate with the overall quality and effectiveness of clinical documentation in the communication of patient care.
• Embrace the concept and remain true to the purpose of the medical record: The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication. Clinical documentation serves to track a patient’s condition and communicate the author’s actions and thoughts to other members of the care team. (Clinical documentation in the 21st Century: Executive Summary of Policy Position Paper from the American College of Physicians)
• Develop, implement and monitor Key Performance Indicators that more closely approximate and measure achievement of clinical documentation effectiveness and completeness. Examples of more relevant measures of documentation improvement include trended volume and dollar amount of medical necessity denials, clinical validation denials and DRG down-codes, number and dollar amount of medical necessity denials in appeals, average cost to collect on medical necessity denials, overall appeal overturn rate on medical necessity denials, and dollar amount and volume of denials associated with patient encounters under the CMS Two Midnight Rule
• Support efforts, commit resources and hold Clinical Documentation Leadership accountable for rebranding the role of clinical documentation improvement program to achieve measurable meaningful results that are sustainable and pertinent to communication of fully informed coordinated care. To this end, CDI initiatives will best enhance alignment and integration with the revenue cycle while supporting value based delivery models moving forward.

Status quo and complacency is always a profession’s worst enemy, particularly in the field of CDI where the need for complete and accurate clinical documentation continually evolves. The CDI profession must come to terms that present day processes centered around reimbursement and diagnoses capture no longer suffice for the increased uses of the clinical documentation as throughput measures for calculation of quality, value, measures of efficiency and effectiveness of care, not to mention heightened need for establishment of medical necessity. Don’t let complacency get the best of the profession, urgent action is necessary today.