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Keywords Clinical Documentation, CDI, Revenue Cycle

Date posted: Wednesday, September 25, 2019

Category: Billing

There recently has been much discussion on the merits of changing the name of the CDI profession from Clinical Documentation "Improvement" to Clinical Documentation "Integrity." ACDIS and AHIMA recently announced the consideration of transition from improvement to integrity as a means of transitioning to a more robust encompassing term that reflects the movement of the profession away from the notion of diagnosis and reimbursement capture. The notion of a simple change in a word facilitating transformation to a more encompassing robust role of CDI in the overall scheme of healthcare delivery must be called into question. 

We are all too familiar with "cutting edge" slick marketing where a company engages in promoting "a new improved" product or rolling out a "new product" where in reality, it is the same previous product with merely a new name. This phenomenon is similar to trusty old-fashioned white bread; simply walk down the bread aisle the next time you're in the grocery store and observe how many different varieties of white bread exist. In most people's minds, white bread is white bread. The same holds true for clinical documentation improvement. Merely changing the name to integrity doesn't negate the fact that real transformation of CDI to meet the ever-increasing changing needs of clinical documentation as third party payment models continue to evolve necessitates wholesale redesign and repositioning of current fundamental CDI processes. 

Let's examine present day CDI processes as they exist in the industry, viewed and considered as the benchmark standard of clinical documentation improvement. The query process serves as the stalwart basis for the majority of CDI programs. Putting this in proper perspective, the CDI specialist opens up and reviews the case, identifies opportunities for "improvement" or "clarification," queries the physician as necessary ensuring adherence to AHIMA/ACDIS guidelines, awaits a response from the physician, follows-up with the record to see if the physician responds, then proceeds to log the query scoring a victory from a Key Performance Indicator standpoint. Established, well ingrained, task-based key performance indicators perpetuate the continuation of this ill-conceived model that refers to itself as "clinical documentation integrity." The old adage of Tell Me How I Will be Measured, and I Will Perform Accordingly applies in this scenario. Consider the following Key Performance 

• Number of charts reviewed daily

• Number of queries generated

• Number of queries responded to by physician

• Query agreement rate by physician

• CC/MCC capture rate

• DRG congruence rate-CDI and coder

• SOI/ROM increase under the APR DRG system

• Gross Reimbursement amount associated with the query process

I submit to all CDI and revenue cycle professionals that the above performance measures bear no correlation or resemblance to clinical documentation integrity. A quick lifting of the hood of the car will reveal damaging engine trouble. Open up the hood and take note of all the medical necessity and clinical validation denials, not to mention onslaught of DRG down-grades, and you undoubtedly will come to the same conclusion that present-day CDI processes and the plain name change of Improvement to Integrity fails to materially address the real shortfalls and deficiencies of current CDI programs. Why the CDI profession and associations that represent the CDI industry overlook the obvious is not quite clear to me.

Integrity in the English dictionary is defined by the following: 1) adherence to moral and ethical principles; soundness of moral character; honesty; 2) the state of being whole, entire, diminished; 3) a sound, unimpaired, or perfect condition.

Let's take a close look at the word "integrity," utilizing the above definitional parameters from the vantagepoint of clinical documentation and communication of patient care. Working with several practicing physicians and physician advisors, I have arrived at what I refer to as the ultimate goal of CDI to achieve effective communication of patient care, a strong foundation that the profession must adhere and subscribe to as an integral part of the CDI role in truly securing integrity of documentation. The mission of CDI must incorporate the following elements into the medical record as part of the basis to support meaningful achievement of clinical documentation integrity. Inarguably, merely changing the term "improvement" to "integrity" is a lesson in smoke and mirrors; talk is cheap; meaningful action is needed.

• To achieve the highest order of specific, accurate, detailed medical documentation whereby to ensure the most precise final coding, so that the institution receives the optimal and appropriate reimbursement to which it is entitled based upon care provided and resources consumed

• To produce a medical record, which is the most efficacious communication tool for all healthcare providers rendering care in each case

• To provide accurate, specific, detailed medical documentation whereby to effect enhanced patient safety, as well as efficiency-effectiveness of care efforts

• To provide a medical record, for external reviewers of all types, free of ambiguity, inconsistency, or clinical incompleteness

• To provide a medical record which is defensible relative to external audits

I fully support the adoption of integrity from improvement into the profession's name, provided the industry comes to terms with the critical need to redesign, reengineer, reformulate, rebrand, and reposition current CDI programs from one of transactional, reactive, repetitive, predicated upon the query process and the use of imprecise, invalid, and unreliable, counterproductive, counterintuitive key performance indicators. Couple the word integrity with a redesigned CDI program predicated upon actually working with physicians as constituent and colleagues, recognizing the need to work with physician advisors, case managers, and utilization review in a direct unified approach to achieving documentation improvement with integrity in support of quality patient care and net patient revenue that stands the test of time. I submit to all CDI professionals: do not accept a name change of clinical documentation integrity to be a substitute for long overdue transformation of CDI programs!