My recent blog posts on clinical documentation improvement programs have outlined the real limitations of present CDI initiatives, serving as significant barriers to achieving optimal potential. I had the opportunity to review an established CDI program for purposes of identifying potential areas ripe for process improvement and/or expanding of CDI staff present core competencies and knowledgebase in CDI concepts. At the end of the in-depth assessment and inventory of CDI processes at this facility, I identified several minor structural and process related recommendations that if implemented properly would achieve meaningful improvement in overall quality of the clinical documentation. However, my conclusions at the end of the client site visit highlighted an interesting concept that if followed and addressed will make tremendous strides in enhancing the effectiveness of clinical documentation improvement programs as measured by reduction in the number of repetitive queries for clinical specificity and general improvement in physician behavioral patterns of clinical documentation.

Clinical Documentation Improvement Programs-Problem Solving

CDI programs are predicated on identifying documentation insufficiencies in the record whether they be diagnostic specificity or additional diagnoses supported by clinical indicators, workup and treatment, yet not documented by the physician. Written or verbal compliant queries are generated as the mechanism for securing additional documented diagnoses in the record.  These additional diagnoses are used as the primary mechanism for tracking the overall successes of the program along with resulting increase in case-mix index and other metrics such as improvement in severity of illness, risk of mortality reporting and quality scores. The current structure and process of CDI is geared towards problem solving in the sense the clinical documentation improvement specialist’s role is to solve one major problem, that is addressing identified diagnoses documentation deficiencies in the chart through the process of clinical queries. In essence the main weapon arsenal of clinical documentation improvement specialists is the structured query process with all the emphasis and concern for compliancy and non-leading queries. What is wrong with this approach?

The main limitation in this approach to clinical documentation improvement centers around lack of physician behavior modification in principles of documentation. Physicians either go along with present CDI initiatives and answer queries because an unanswered query becomes a chart deficiency in medical records or they know they will be “requeried” by the coding staff in Health Information Management. Behavior modification often time consists of the physician deviating from the practical application of his/her clinical judgment and documenting the diagnosis with clinical specificity each and every time in similar clinical scenarios. A typical case in point is every time a patient presents with a GI bleed a diagnosis of “acute blood loss anemia” is documented as a secondary condition, regardless of whether the patient’s clinical indicators, presentation and management support the diagnosis. Another typical clinical scenario is the diagnosis of congestive heart failure as a secondary condition when patient may be admitted for pneumonia or any other acute condition. Physicians will have a tendency to document acute on chronic systolic heart failure regardless of whether the clinical indicators and treatment support the conclusory statement of this diagnosis. The clinical facts of the case fail to support the diagnosis, something outside third party payers and Medicare contractors capitalize upon in reviewing and denying diagnoses coded and billed on the premise of lack of clinical validation. Clinical validation versus DRG validation is defined in the Recovery Auditor’s Scope of Work as follows:

  • DRG Validation is the process of reviewing physician documentation and determining whether the correct codes, and sequencing were applied to the billing of the claim. This type of review shall be performed by a certified coder. For DRG Validations, certified coders shall ensure they are not looking beyond what is documented by the physician, and are not making determinations that are not consistent with the guidance in Coding


  • Clinical validation is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials.


Strategy and Innovation

Innovation is long overdue in the clinical documentation improvement arena, current initiatives are stagnating and are in sore need of revitalization. Strategic and innovative components and characteristics can successfully be incorporated into current clinical documentation initiatives with sound development and planning processes. Let’s take a look at how best to approach the development and planning process. The first element that resonates in any strategy to expand and build upon current CDI initiatives is the appreciation and understanding of what the medical record serves for, that is as a communication tool for patient care to all healthcare stakeholders including the patient as well as tool for telling and retelling the patient story. Appropriate reimbursement for services provided is separate and distinct and a byproduct of good documentation. We must as a clinical profession recognize that efforts to improve clinical documentation are not and should not be our reason for being, period!  We need to get out of the mindset of the Easter bunny scurrying around looking for egg (CC/MCCs) on Easter Sunday, crafting compliant queries and coming up with an egg when it is positively answered by the physician.


Any efforts at strategic and innovative improvement in clinical documentation improvement programs must embrace a thorough understanding of what constitutes complete, accurate and effective clinical documentation. We cannot possibly know what to strive for in true clinical documentation improvement if we fail to have a strong understanding of where we are now in comparison of to where we should be. How do we acquire this knowledge and understanding of concise, complete and accurate clinical documentation? First and foremost is taking the initiative to work with our physician advisors, medical directors, chief of staff, president of the medical staff and section chiefs to develop a standard for effective clinical documentation that serves the numerous additional needs under the performance, quality and value based healthcare transformation delivery models. Efforts at developing a reasonable, reliable and valid documentation standard will undoubtedly be a long, pain staking process whose fruit will be well worth the effort.

In my next blog, I will outline several suggested time tested and proven ideas to consider in strategically and innovatively incorporate into your current clinical documentation initiatives that will have positive impact the overall quality and effectiveness of clinical documentation beyond reimbursement. Physicians taking back command of the clinical documentation process which has been degraded by the structured format and context of the electronic health record through mobile apps that promote the recording of the physician’s clinical judgment, medical decision making and thought processes intuitive to the practice of medicine.