Five crucial points to consider-strengthening CDI programs towards optimizing the revenue cycle

Glenn Krauss, Founder and Creator, Core-CDI.com - Print  | 

Clinical documentation improvement programs have existed for more than ten years, however as the overall healthcare delivery and reimbursement models continue to change, the CDI profession and hospital industry has failed to sufficiently evolve to meet the increasing needs for more accurate and complete documentation.

Current hospital CDI initiatives primarily focus on the query process to clarify and secure diagnoses impacting reimbursement through case-mix attribution or reporting of quality measures. The hospital industry and CDI profession is missing a real opportunity to transform present CDI initiatives toward achieving true documentation integrity that delivers performance with combine purpose: optimize patient care, quality outcomes, measures of cost effectiveness and value proposition, and integrity of the revenue cycle. The following five points must be addressed in order to transform present CDI initiatives.

1. Clinical documentation improvement programs should focus on achieving complete and accurate capture, reporting and reflecting of the patient clinical story from Emergency Department presentation through decision to hospitalize the patient, clinical progression of patient while in the hospital until patient discharge.

2. In order to realize optimal performance of CDI programs with effective return on investment, CDI professionals cannot operate within a vacuum, reviewing records retrospectively in a transactional repetitive reactionary work process that relies predominantly on issuing queries for diagnosis clarification. Achieving a higher level of effectiveness requires CDI to partner with case management, utilization review, and other ancillary healthcare stakeholders. Working together as an integrated team will affect positive change in documentation that best serves the patient, the physician, the individual roles of the stakeholders, and ultimately the performance of revenue cycle.

3. The fundamental CDI structure and operational processes must embrace and incorporate the concept of solid and complete documentation and communication of patient care to insure the establishment of medical necessity for the most clinically appropriate hospital level of care.

4. A major mission of CDI must be to collaborate synergistically with physicians to advocate for, promote, and achieve documentation standards that demonstrates and reports the right patient care at the right time for the right reason in the right venue. Documentation must consistently include the physician clinical judgment and medical decision making supported with appropriate clinical documentation.

5. Key Performance Indicators must go beyond relying on reimbursement-based outcomes and task-based CDI actions (including chart review query rate that generate case-mix increases) to measure general success and effectiveness of CDI initiatives. Other valid and more reliable Key Performance Indicators to consider include medical necessity volumes and dollar amounts, clinical validation denials and DRG down-codes, cost to collect, various denials overturn rates, average receivable balances tied up in appeals, average time in appeals process, and initial and concurrent rate and volume of third-party payer adverse level of care determinations

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