Clinical Documentation Improvement: What Executives Need to Know and the Financial Impact of Neglect

Everything hospital executives need to know about the importance of clinical documentation improvement is summed up in one single fact: CDI fuels correct reimbursement and accurate quality reporting. Beyond this fact lies a myriad of people, processes and technology that must work together to ensure CDI programs meet these goals.

Organizations that choose to neglect or underfund CDI initiatives are at risk for weak revenue and suboptimal Healthgrades reporting. Herein lies the need for executive understanding and awareness of CDI.Dianne Haas

What is CDI?

Because clinical documentation is at the core of every healthcare encounter, it should be complete, precise and reflect the scope of care and services provided. Assuring consistency in provider documentation that is accurate, specific, legible and timely represents a challenge for many organizations.

Physicians and other healthcare providers typically are not trained to develop proper documentation skills in medical school and residency, nor do NPs and PAs receive such training during graduate school and clinical rotations. Hospitals and healthcare systems need to compensate for this lack of training by instituting educational programs and tools that align healthcare providers with proper documentation practices and remove barriers to achieving CDI.   

Allocating resources to CDI training and development is an investment that will produce future returns for healthcare organizations. These include:

  • Robust, concise and complete documentation that reflects the delivery of high-quality healthcare services
  • Support for the coding of medical records to their greatest level of specificity
  • Ability to meet revenue cycle goals, such as submission of clean claims and reduction in days in A/R

Negative impacts of neglect

The negative impacts of poor quality documentation are many. This is particularly true for multi-location healthcare organizations and those sharing data within a health information exchange or accountable care organization. At a minimum the following risks are well documented and should be clearly understood by healthcare executives.

  • Clinical coding is based solely on the medical record (clinical) documentation by the physician. Coders are only permitted to code what is documented by physicians and other providers such as NPs and PAs. Therefore coding, reimbursement and case mix are directly impacted when documentation is missing, unclear or insufficient. Coders are forced to use non-specific codes, resulting in lower-paying DRGs and faulty case mix index.
  • Quality scores and Healthgrades reporting are also based on coded data — again stemming from the clinical documentation in the medical record. Quality scores could be falsely reported due to improper documentation, placing organizations in a one-down position in local and regional care markets.
  • Ongoing patient care is impacted when the next physician in line is unclear or misinformed.
  • Additional costs may be incurred as physicians are forced to repeat tests and exams when the original, treating clinician failed to fully document what was performed, ruled out or treated.

Physicians are key players

Clearly, physicians and their extender colleagues play a critical role in clinical documentation improvement. Executives must respect their position and listen to their concerns.

Since the implementation of the MS-DRG system, it is more important than ever for physicians to familiarize themselves with and capture all the patients' diagnoses and appropriately document the severity of illness. This includes complete and correct documentation of all complications and comorbid conditions that either directly or indirectly affect the MS-DRG relative weights.

Now with the 2014 transition to ICD-10, representing approximately an eight-fold increase in the number of accessible codes, the importance of clinical documentation has become even more pronounced. The role of an outstanding CDI program to underpin this transition cannot be understated.

With ICD-10, physicians, NPs and PAs must thoroughly document each and every diagnosis to an even greater level of specificity than is required with ICD-9. Non-specific or incomplete documentation within ICD-10 results in a generic code, lower reimbursement and inaccurate quality reporting. Definition and terminology changes inherent within ICD-10, particularly for surgical procedures, will also require focused CDI initiatives, education and training.

Integrate efforts for maximum return

Finally, executives should understand the importance of integrating CDI efforts throughout the entire organization and across departmental silos. CDI professionals, medical staff, revenue integrity experts and clinical coders must be seated at the same table to positively impact reimbursement and quality reporting.  

Organizations that coordinate documentation by bringing together CDI professionals and clinical coders report a reduction in RAC take-backs and third-party payor audits. Stronger documentation teams have resulted in better financial outcomes for all.

Once CDI, coding and revenue teams are integrated, physicians should be brought into the CDI program. This ensures physicians hear a consistent, unified message regarding specific documentation issues, and further strengthens overall program efforts.

Where to start

Establishing and sustaining an effective CDI program should be top priority for all healthcare organizations. For those with no CDI program in place, the time to begin is now. It is the key to supporting physicians, NPs and PAs through the ICD-10 transition.  

For those with CDI programs already underway, now is the time to fine-tune and focus efforts on areas of greatest financial impact under ICD-10 or pay-for-quality initiatives. Second-generation CDI efforts must be formalized and pursued. This is particularly true for hospitals acquiring physician practices as documentation improvement efforts in the hospital environment also support better coding and billing in ambulatory and office settings.

Resources and information are available through both the American Health Information Management Association and the Association for Clinical Documentation Improvement Specialists, which can provide guidance on the nature of optimal CDI programs. Engaging an external resource in a CDI audit can be a beginning step at looking at the efficacy of current organizational CDI efforts that are under way. Depending on results from the audit, a roadmap for process improvement could evolve. If your organization has not yet begun a CDI program, there is no need to panic. However, there is no time to wait.

More Articles on CDI:

How Clinical Documentation Improvement Could Improve the Revenue Cycle
Clinical Documentation Specialists Can be Sturdy RAC Defense

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