What is Clinical Documentation Improvement (CDI)?
The Purpose of CDI
Initially known as Clinical Documentation Improvement, now is known as Clinical Documentation Integrity.
The purpose of CDI is to identify discrepancies in physician documentation and help physicians accurately capture the patient’s health conditions during an encounter. This is done through a compliant query practice. Queries are questions made verbally or in writing to the healthcare provider to clarify inconsistent, incomplete, conflicting documentation. Queries provide the opportunity for the physician to document their thought process to support a condition documented, that does not seem to be clinically supported, or eliminate it from the documentation.
CDI practices were initially done in the inpatient setting (while the patient was in the hospital) in adult acute care hospitals. Now CDI has expanded, including pediatric services and outpatient encounters.
CDI’s Impact of Revenue Cycle
Given that healthcare reimbursement is directly tied to physician documentation, CDI specialists are key to the healthcare facility’s revenue operations. Healthcare reimbursement has a system of checks and balances in place to prevent fraud and abuse.
Physician documentation gets translated into codes. Those codes are placed on the bill sent to the insurance company for reimbursement of the care provided to their patient. The insurance company will review the codes, and compare them to the physician documentation, to ensure that all revenue-impacting codes are accurate. If discrepancies are found, the insurance company may underpay the claim or request a refund (if reimbursement has already been provided to the healthcare facility).
A CDI program would assist in helping correct any discrepancies in documentation prior to billing an encounter. This would prevent situations of over-coding or under-coding an encounter, in turn resulting in appropriate reimbursement for the care provided. CDI specialists also help maintain healthcare compliance and support patient care and safety.
Regulatory Compliance
Healthcare compliance is very broad, as it requires every employee in an organization to do their part in observing the rules and regulations that apply to their operation.
CDI personnel must maintain compliance with HIPAA regulations and ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice briefs. CDI specialists must also abide by ethical standards, as promoted by AHIMA/ACDIS, and all official coding rules and guidelines.
For example, a CDI specialist that does not send a query, could trigger a Patient Safety Indicator (PSI), which could result in a monetary penalty for the healthcare system, and is not abiding by AHIMA/ACDIS ethical standards. Queries should be sent if documentation needs clarification, regardless of potential financial impact.
The Risk of Non-Compliance in CDI
Increased Denials
Aggressive query practices also result in non-compliance. This refers to the practice of sending queries to capture codes for conditions that are barely clinically supported, or that did not impact patient care. This results in over-coding, which in turn, results in increased denials. This can negatively impact revenue, as the healthcare facility also incurs in appeal costs for conditions that should never have been queried.
In our practice, for example, we may see a query sent for sepsis, where the patient only had tachycardia (one elevated heart rate during the entire stay), along with leukocytosis in the setting of an infection but was otherwise stable throughout the entire stay. Even though the patient “technically” met Sepsis 2 criteria, a query in this scenario would lead to a denial of payment, since the patient was not identified as ill-appearing or with acute organ dysfunction related to infection. The account might go through a first level appeal, second level appeal, and/or other alternative avenues of dispute, increasing the cost the hospital incurs in trying to obtain increased reimbursement, for care that was really not provided to the patient.
Legal Consequences
Another consequence of aggressive query practices is that it places the healthcare organization at risk of increased audits, investigations, and potential fraud charges. This would negatively impact the healthcare facility due to negative press and increased regulatory scrutiny.
An example is Independent Health, a Medicare Advantage provider, who agreed to pay $98 million to settle a False Claims Act lawsuit. The U.S. government accused the company of submitting false claims for services that were not properly documented, through retrospective query practices, leading to overpayments from Medicare. The settlement resolves allegations that Independent Health failed to comply with documentation and coding requirements, causing improper reimbursements. The company did not admit liability but agreed to make compliance improvements. [1]
Financial Penalties
CDI personnel, like all employees who have access to medical record information, must also protect access to medical records information to prevent breaches. Breaches result from violations to HIPAA regulations and places the organization at risk of cyber-attacks and penalties for unauthorized information use.
For example, in May 2018, the US Department of Health and Human Services’ Office for Civil Rights (OCR) initiated an investigation of Yakima Valley Memorial Hospital following the receipt of a breach notification report, stating that 23 security guards working in the hospital’s emergency department used their login credentials to access patient medical records maintained in Yakima Valley Memorial Hospital’s electronic medical record system without a job-related purpose. The information accessed included names, dates of birth, medical record numbers, addresses, certain notes related to treatment, and insurance information. As a result of the settlement agreement, Yakima Valley Memorial Hospital agreed to pay $240,000 settlement and to be monitored for two years by OCR to ensure compliance with the HIPAA Security Rule. [2]
Patient Care
When physician documentation is unclear or inconsistent, this impacts patient care as misleading documentation may affect clinical decisions, delay treatment, and/or result in unexpected complications in care. Inaccurate diagnoses may lead to poor patient outcomes.
How To Mitigate The Risk of Non-Compliance
Regular Audits
To mitigate the risk of non-compliance, conducting regular CDI audits will help ensure query compliance and record completeness. An audit’s purpose is to look for noncompliant queries, missed query opportunities, and provide this information to CDI specialists as educational opportunities. Audit frequency is based on your facility needs, but a quarterly cadence is most common.
Sharing the overall missed query opportunities identified during an audit with the CDI team will enable each CDI professional to recognize additional query opportunities and avoid falling into a repetitive pattern of querying for the same conditions. Depending on the facility’s CDI software, accounts may also be flagged for secondary review (outside of the formal audit system) when there is a long length of stay and no major complications or comorbidities (MCC) codes, low severity of illness (SOI) score and discharge to hospice or mortality, or DRGs targeted by denials.
Query templates should also be reviewed at least annually to ensure compliance with ever-changing rules and regulations.
Find An Experienced Partner
Having a third-party CDI auditor provides several advantages, such as having a non-biased specialist performing the evaluation, and obtaining different perspective on missed opportunities.
At Managed Resources, our team of seasoned CDI specialists are passionate about identifying missed opportunities and compliance issues. Since our team is also involved in appeal efforts, we have a unique ability to identify missed query opportunities that will not cause a denial in the backend. Our team provides the following CDI services:
- Concurrent Reviews
- Retrospective Reviews
- Compliance Reviews
- CDI Staffing
- Trends & Procedure Analysis
- Education & Training
- Denial Mitigation
We strive to deliver prompt and actionable audit results. Our rebuttal process also ensures that our clients have an opportunity to review the results and discuss any findings before finalizing the audit. We take the time to customize the results presentation to fit our client’s purpose, whether to educate their CDI team and/or provide data to their executives, we want to make sure our clients obtain the information they need in the format that they need it.
To learn more about Managed Resources’ CDI Services, please contact us here.
