The term “Clinical Documentation Improvement” is synonymous with impacting case mix index and CC/MCC capture clinical specificity.  Does Clinical Documentation Improvement equate to achievement of effective clinical documentation. Are the terms synonymous, mutually exclusive or synergistic in nature?

Clinical documentation improvement specialists should be striving to achieve in each and every chart we review complete, accurate and effective clinical documentation, not just documentation that increases the case mix index, reimbursement and alleged return on investment. I reference “alleged” since most programs calculate their ROI strictly based upon gross increase while in reality the ROI should be based upon net increase computed by subtracting outright medical necessity denials and cases that are downcoded on the basis of questionable clinical validation of the CCs/MCCs we queried for that are subsequently disallowed by third party payers.

Elements of effective clinical documentation include the following objectives:

  • Accurately tells and retells the patient story
  • Completely and concisely communicates the need for current patient care, clinical status including specific diagnoses, comorbidities and past medical history impacting current patient care, plans for current and future care and time frame for follow-up
  • Promotes cost effective discharge planning and ongoing chronic care coordination within the healthcare delivery system
  • Properly represents and reflects physician clinical judgment, medical decision making, thought processes, analytical skills and problem solving ability
  • Allows for the accurate assessment, planning, implementation, continuity and evaluation of quality medical care
  • Clearly establishes and supports medical necessity and level of care for all services or supplies provided or ordered at a specified time
  • Robust and adequate to support the goals and objectives of physician advisors, case managers/discharge planners and utilization review staff
  • Insures the accurate answers to the following questions:

o             Who?- Who is performing the service?

o             What?- What type of services are performed?

o             How many?- What are the quantities of services performed?

o             Where?- What is the place of service?

o             When?- When is the date of service?

o             Why?- Establishing medical necessity and diagnosis

Just some food for thought as you evaluate the effectiveness of your CDI program. The real question is how effective is your CDI program?  No telling unless you take an adequate assessment and inventory, I am confident you will be surprised by this assessment.