Healthcare delivery is a challenging environment with an unlimited number of competing forces working against providers. A major challenge of all providers is insuring an efficient and effective revenue cycle process that incorporates a strong clinical documentation, coding and billing process that can withstand the pressures of third party payers relentlessly second guessing the clinical judgment of physicians as represented in their diagnostic conclusory statements in the record and subsequent ICD-9 and MS-DRG assignment by the coding staff. Third party payers conduct clinical validations of medical records to determine if the clinical information in the chart substantiates and supports the diagnoses on the claim as coded and billed. Unfortunately, clinical documentation improvement programs create the potential to fuel the fire for clinical validation reimbursement take backs from third party payers.

Let’s take a look at the operations of a typical clinical documentation improvement program and examine how these programs may contribute to increased medical necessity and clinical validation denials. Clinical documentation improvement programs strive to insure all relevant diagnoses associated with patient care are documented in the chart reflective of patient acuity and severity of illness. This process involves the clinical documentation improvement specialists regularly reviewing charts and identifying potential opportunities for increased clinical specificity or additional diagnoses being managed, evaluated and treated and that are not documented. A written non-leading query is generated with a focus upon inclusion of all relevant clinical indicators serving as the basis for the clarification of specificity or addition of diagnosis. The physician may or may not answer the query and if the physician agrees with the inclusion of the diagnosis through his/her documentation, the results are tracked for matrix reporting of the CDI program.

What is missing from CDI Programs?

There are actually two key components missing from most CDI programs that contribute significantly to medical necessity and clinical validation denials from third party payers including Medicare as well as private insurers. Let’s take a look at the medical necessity component. CDI focuses upon missing or incomplete documentation of clinical specificity and acuity through chart review and the query process. The increasingly important context of the admission and a clear depiction of the clinical facts of the case and concerns of the physician that ultimately led the physician to the complex decision to admit the patient as an inpatient versus observation status are not well documented in the chart. Take for instance the controversial Medicare two mid-night rule for presumption and benchmark of a medically necessary inpatient admission. In short, a Medicare inpatient admission is presumed to be appropriate from a medical necessity standpoint if the physician in his/her clinical judgment has a reasonable expectation of at least a 2 mid-night stay where the workup and care is medically necessary. The care provided must be reasonable and necessary and must require a reasonable expectation of at least 2 mid-night stay in the hospital.

The key words here are “reasonable expectation” and this is often times problematic in the sense the physician documentation fails to support a reasonable expectation. Prior to October 1, 2014 for Fiscal Year 2015 IPPS, the physician was required to “certify” through a certification form the reasonable expectation of at least a 2 mid-night stay. This formal certification requirement has since been removed but the reasonable expectation of a 2 mid-night stay as evidenced in the documentation still remains. Unfortunately, insufficient documentation in support of the 2 mid-night rule still is problematic and pervasive throughout the medical record. CMS simplified the language associated with the two mid-night rule in a November 9, 2014 Federal Register notice using the following language (page 229-230):

  • A beneficiary becomes a hospital inpatient when admitted as such after a physician (or other qualified practitioner as provided in the regulations) orders inpatient admission in accordance with the CoPs, and Medicare pays under Part A for such an admission if the order is documented in the medical record. The order must be supported by objective medical information for purposes of the Part A payment determinations. Thus, the physician order must be present in the medical record and be supported by the physician admission and progress notes in order for the hospital to be paid for hospital inpatient services.
  • As noted above, we believe that, in most cases, the admission order, medical record, and progress notes will contain sufficient information to support the medical necessity of an inpatient admission without a separate requirement of an additional, formal, physician certification.


Clinical Documentation Improvement

The securing of clinical specificity and all relevant diagnoses without incorporating solid documentation of the context of the patient admission including an accurate story of the patient’s history of present illness, physician’s clinical judgment, thought processes, medical decision making, clinical reasoning, relevance of available diagnostic results at time of admission and well laid out plan of care congruent with the physician’s assessment of the patient, serves little purpose. Reference the medical necessity denials for common MS-DRGs identified by Palmetto GBA in a presentation titled “Spotlight on Physician Querying  and Coding Specific Diagnosis Related Groups”$File/Spotlight_on_Physician_Querying_and_Coding_Specific_Diagnosis_Related_Groups_(DRGs).pdf

Now for the second point of clinical validation denials. The foundation for a compliant non-leading query is the inclusion of clinical indicators in the drafting of the query. While the physician may answer the query, the physician’s clinical judgment and reasoning in arriving at the diagnostic conclusory statement documented in the chart using these same clinical indicators is not recorded in the record. Consider these diagnostic statements being “dropped” in the chart without documentation of clinical rationale and reasoning as solid ammunition and contributory factors in ongoing medical necessity and clinical validation denials.

The Coding Role

Coders are charged with reviewing the medical record including H & P, progress note, lab, radiology and other diagnostic test results, Emergency Room documentation, consult reports and in some cases nurse’s notes. As part of this review process, coders apply official coding guidelines as well as guidance offered by the Coding Clinic often in the face of incomplete and inconsistent clinical documentation.

One major role of the coder is to assign the principal diagnosis for the case, that is deciding which admitting diagnosis was chiefly responsible for occasioning the admission to the hospital after hospital workup and study. This role becomes that more challenging and difficult without accurate and complete clinical documentation in support of the admission and patient care actually provided. Clinical Documentation Improvement Specialists do not necessarily help the cause of selecting the most clinically relevant principal diagnosis without the “holistic documentation” that clearly outlines the chief reason after study that occasioned the admission as well as any secondary conditions that impact the management of complexity of his chief reason for admission.  Holistic documentation is not furthered and promoted by the leaving of queries to clarify a diagnosis or diagnosis specificity without documentation that supports the admission as well as the physician’s intensity of the evaluation and/or treatment, including thought processes and the complexity of medical decision making in the workup and management of the patient as part of the hospitalization process.

A possible solution is for the clinical documentation improvement specialists to work in conjunction with case management, utilization review and physician advisors in promoting and changing physician patterns of documentation to more accurately reflect the clinical presentation and care provided, recognizing that the record serves as a communication tool for patient care and improvement in clinical outcomes. Reimbursement is a byproduct of quality documentation correlating with quality care.

Lots of work to do….Time is of the essence