Clinical Bundles

Bundles of care exist for serious disease processes with tendencies toward greater mortality rates such as sepsis. These bundles consists of standard checklists of care interventions that have demonstrated increased efficacy in overall treatments that are cost effective, efficient,  drive notable decreases in morbidity and mortality while improving the cost and value equation of outcomes in today’s transition to performance based healthcare delivery model. A similar concept of succinct bundles can be created for the clinical documentation improvement that affects positive change in physician behavior patterns of clinical documentation.

Clinical Documentation Improvement Limitations

I have written and blogged extensively on the marked limitations of current CDI initiatives centered on CC/MCC capture and quest for case-mix and resulting reimbursement increases for the hospital. Granted CDI programs, operating much like any other healthcare business, must be self-sufficient and self- supporting when it comes to expense and measurable revenue creation. Just the same, our present path of primary focus upon solidifying clinical documentation in support of additional reimbursement is simply not a sustainable model as the need for complete, accurate and effective documentations spans well beyond reimbursement with the transition to value and performance based healthcare delivery models. At the crux of this value and performance based delivery models is achievement of efficient, cost effective healthcare outcomes with a strong emphasis upon preventive medicine and population health management. An integral component of these new delivery models is insuring the right care at the right time for the right reason in the right venue with the right clinical documentation.

Securing documentation of diagnoses for reimbursement purposes without regard for documentation of clinical context, i.e., establishment of medical necessity for the service ordered and/or provided by the physician serves no meaningful purposes and is counterintuitive to communication of patient care and the accurate reporting and depiction of the practice of evidence based medicine. Case in point is the sheer number of inpatient cases denied by Medicare contractors due to lack of documentation establishing medical necessity. Palmetto GBA, the MAC for NC, SC, VA and WV, in June, 2014 released a presentation titled “Spotlight on Physician Querying and Coding Specific Diagnosis Related Groups.” In this presentation, Palmetto highlighted the top 25 MS-DRGs billed in their region and the associated claims denial rate percentages. Two high volume DRGs in NC with large claims denial rates included DRG 291- Heart Failure and Shock with MCC and DRG 292- Heart Failure and Shock with CC. The claims error rate for the DRG 291 was  89% with 99% of the denials related to the need for service not medically necessary and the claim error rate for DRG 292 pegged at 93% with need for service not medically necessary at 99.1%. Similar results were found in their other three jurisdiction states. The 2014 CERT Paid Claims Error Rate increased to 12.7%, representing $45.8 billion in improper payments, compared to the FY 2013 improper payment rate of 10.1% or $36 billion in improper payments. Inpatient admissions accounted for a 13.8% improper payment rate with 50.6% of the improper payments attributable to medical necessity issues.  (The Supplemental Appendices for the Medicare Fee-for-Service 2014 Improper Payments Report). Results for the first quarter CERT 2015 improper payments 2 demonstrate the same results. Clinical documentation demonstrating a clear picture of medical necessity for services rendered and provided is paramount is paramount to communication of patient care.

Clinical Documentation Bundles

Clinical documentation bundles can be created as part of an effective strategy to enhance communication of patient care with the expanded need for consistent, accurate and clear medical record documentation as Medicare and other payers migrate towards alternate payment and healthcare delivery models. These clinical documentation bundles by their very nature expand the horizon of focus of clinical documentation improvement specialists beyond strict capture of reimbursement through CC/MCC and principal diagnosis specificity clarification.

Clinical documentation bundles serve as a roadmap for the accurate and complete capture and reflection of patient care as well as physician clinical judgment, medical decision making, thought processes, problem solving ability, and clinical reasoning, all required for effective communication of healthcare to all stakeholders. If physician clinical documentation explicitly records salient points of each element above, efficient and effective care choices unequivocally demonstrating medical necessity will be achieved. Let’s take a look at the components of an encompassing clinical documentation bundle.

The following components represent key integral parts of an encompassing clinical bundle:

  • Chief complaint and nature of presenting problem- accurate and completing recording of why patient is seeking healthcare care in the patient’s own words
  • History of present illness that accurately records a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present. This includes a description of location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms significantly related to the presenting problem(s), all vital to setting the tone for establishment of medical necessity for physician work performed downstream and the substantiation of medical necessity for hospitalization, whether inpatient or observation designation
  • Physical Exam commensurate with the nature of presenting problem and History of Present Illness, congruent with the chief complaint HPI and Review of Systems
  • Medical decision making reflective of physician supporting criteria and the amount of work performed in establishing diagnoses and selecting management plans. Documentation should include clinical significance of available diagnostic tests and their relationship to provisional and established diagnoses, the clinical rationale of ordering additional tests and/or therapeutic treatment and linkage to provisional or established diagnoses, all supportive of the established plan of care. In short, the documentation should clearly outline the physician’s clinical reasoning and judgment for where I currently am with the patient and where am I going, defined as performing and recording an accurate assessment of the patient’s particular clinical scenario and the initiation of action congruent with this assessment
  • Documentation in the assessment that supports the planned intensity of evaluation and/or treatment, including recording of thought processes and the complexity of medical decision making.
  • Assessment containing provisional diagnosis(es) associated with symptom(s) if definitive diagnoses are no currently known at the time of admission and/or definitive diagnoses, all recorded with associated with clinical specificity, i.e., acute, acute on chronic, etc.
  • A plan of care congruent with the recorded patient assessment, physical exam, History of Present Illness and chief complaint. The documentation should support a clear picture of where the patient was, where is the patient now and where is the physician going with the planned management of the patient
  • Plan of care that reflects estimated time frame (length of stay) for the patient’s work up and treatment and post-acute care discharge plans
  • Continuity of documentation in the progress notes that outlines the patient’s progress including response to treatment, any changes in diagnosis, and clear depiction of patient’s current clinical stability to substantiate continued need for hospital level of care, workup and treatment. Progress notes should reflect the actual progress of the patient, adhering to the following constructs:
    • Patient is unstable or has developed a significant complication or a significant new problem
    • Patient is responding inadequately to therapy or has developed a minor complication
    • Patient is stable, recovering or improving
  • Discharge summary clearly outlining the hospital admission including the reason for admission, hospital course, condition at discharge and plans for follow-up care. The Joint Commission outlines the following components that each hospital discharge summary should contain:
    • Reason for hospitalization
    • Significant findings
    • Procedures and treatment provided
    • Patient’s discharge condition
    • Patient and family instructions(as appropriate)
    • Attending physician’s signature

The National Quality Forum Safe Practice #15 Discharge Systems discusses discharge summaries and the Society for Hospital Medicine has proposed checklists for discharge summaries. Learn more about recommended content of discharge summaries by reading “Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care” ( and “Creating a better discharge summary” that appeared in the March 2009 ACP Hospitalist magazine (


Final Words

The time has come for Clinical Documentation Improvement Programs to recognize that present efforts at documentation improvement are counter intuitive to accurate communication and reporting of patient care and in fact contribute to increased medical necessity denials. Consideration must be given to evolving into affecting positive change in physician behavior patterns of documentation. Embracing clinical documentation bundles and engaging physicians in an open, active discussion of true clinical documentation improvement with incremental change in practice patterns of documentation is essential for transitioning into value and performance based healthcare delivery models. The status quo of today’s CDI program’s focus upon CC/MCC capture and case mix increased is destined for eventual distinction, the way of industries such as movie rentals and chain bookstores.




CERT Program 2014

Spotlight on Physician Querying and Coding Specific Diagnosis Related Groups$File/Spotlight_on_Physician_Querying_and_Coding_Specific_Diagnosis_Related_Groups_(DRGs).pdf