ACDIS tip: CDI specialists use legal, coding, and clinical knowledge

By Kathryn Fallah and Karla Accorto

CDI is a mix of three categories blended into one, according to Dawn Valdez, RN, LNC, CCDS, CDIP, CDI education specialist with ACDIS in Middleton, Massachusetts. These three categories are:

• Legal
• Coding/billing
• Medical/clinical

The legal category deals with query writing, ethics/compliance issues, and finances. Coding and billing knowledge is needed so that the CDI specialists can determine what the DRG would be as well as the expected length of stay and reimbursement. The clinical category deals with educating providers on the documentation needs for coding and billing and understanding clinical indicators for numerous diagnoses.

CDI specialists must learn the clinical aspects of healthcare in order to appropriately identify query opportunities. For example, if multiple physicians document conflicting diagnoses, the CDI specialist would need to clarify the conflict through the query process by offering appropriate choices based upon the clinical indicators present. Additionally, CDI specialists need to understand coding and billing rules to be able to assign a working DRG that accurately reflects the level of resources the patient consumed.

Because medical records are legal documents, it is essential that they be as accurate as possible, and the accuracy of the medical record relies heavily on the identification of query opportunities existing within the documentation. Therefore, perhaps the most important skills a CDI specialist can learn is how to identify query opportunities and draft compliant queries. Queries clarify documentation that is incomplete, conflicting, or ambiguous, but they can also serve to clarify a situation in which the provider describes a diagnosis by its clinical indicators but does not officially document the diagnosis (often referred to as a clinical validation query). If a medical record doesn’t include documentation of the specific diagnosis, it cannot be captured in the final billing statement.

“If something isn’t documented in a medical record, then it wasn’t done,” at least in the eyes of a court of law, says Valdez. For example, if a patient was admitted to a facility with pneumonia and developed sepsis, the physician should capture that information in their documentation. If a physician failed to capture all the necessary information in their clinical documentation, it could look like that patient was not as ill as he or she actually was. In the future, if a physician is looking for the medical history for that same patient, any lost documentation could impact patient care.

To ensure a complete and accurate medical record, CDI specialists can clarify the documentation through the use of several different types of queries. According to the ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice” brief, open-ended queries are the most frequently used, but in Valdez’s experience, multiple-choice are just as popular. Some specialists may also use verbal queries and they have a specific use, as some clinical scenarios require a verbal conversation with a provider. This type of query can be pre-written so that the physician can document the query response after the CDI professional verbally presents the clinical indicators; however, in that situation, it is important to be careful not to lead the physician to the desired answer. This may happen either accidentally or intentionally, but all leading queries are noncompliant.  

Submitting a noncompliant query can lead to many complications down the line. For example, some diagnoses are subject to audits by recovery audit contractors (RAC) prior to payment. A RAC will look at the case, and if they identify a noncompliant query, they can downgrade the diagnosis attached to the query and deny it. This often results in a DRG change, which means a lower reimbursement rate.

Organizations who seek seemingly excessive reimbursement may also face additional scrutiny and penalties. For example, let’s say an organization submits a bill with a lot of perceived overcharges. That would put the organization on the auditor’s radar, and the auditor would likely scrutinize the bill or even every bill from that facility, depending on the history of prior denials identified. Additionally, the auditor could choose to alert other auditors in the area. When multiple auditors are wary of your claims, you’ll be at risk of an Office of Inspector General investigation, which could result in millions of dollars in fines and create a financial hardship for hospitals, especially smaller facilities. 

There is truly no doubt that CDI specialists play a significant role in the healthcare world. They are the bridge between the coding and medical spheres and therefore ensure that their organizations receive accurate and appropriate reimbursement for the care provided.

Editor’s note: Fallah and Accorto are PROPEL CDI member liaisons. For more information about PROPEL CDI, please contact Julie McCoy (jccoy@hcpro.com).