Guest Post: CDI efforts matter in changing healthcare landscape

By Cathy Farraher, RN, MBA, CCM, CCDS

One of my favorite cartoons that pertains to CDI shows a gentleman in a hospital bed shouting at the nurse. She is standing at the foot of his bed holding a clipboard. (Remember when we used to leave patients’ personal information on clipboards attached to the foot of the bed? That was way back in the days before the Health Insurance Portability and Accountability Act [HIPAA].) The patient in the cartoon is shouting, “I don’t care what the chart says, I did NOT have a hysterectomy!”

As funny as the cartoon is, it represents an astonishing truth about our heretofore accepted care in America’s health system illustrated by the 1999 Institute of Medicine report “To Err is Human: Building a Safer Health System.” The report shocked the nation, showing that potentially as many as 98,000 people die in hospitals each year as a result of medical errors that could have been prevented.

The report spurred an age of healthcare reform that has yet to prove its mettle.

While the anecdote illustrated by the cartoon essentially shows a no-harm situation, it definitely shines a light on the problem and importance of documentation accuracy and concurrent medical record reviews. The reality is this sort of situation occurs more than we would like to admit—enter the need for CDI clinical validation queries.

Healthcare has changed a lot since I entered the field many years ago, and everyone believes there are changes still to be expected. Back in the old-old days, long before my time, patients lingered in the hospital for days after delivering a healthy baby from an uneventful pregnancy. My mom told me how great it was to have a baby since you got to stay in the hospital for a week. Back in the way-back days, having any type of surgery was bound to buy you a little “vacation” from life. I remember my grandfather being a patient in the hospital because he had “hardening of the arteries” (which I am pretty sure was another name for dementia). And I remember my little brother and I having our tonsils out together and being there for a few days.

Fast forward to today. Those concerns listed in the 1999 report pushed for care to be provided in “safer” settings, outside the hospital walls. But this push led to outpatient care being provided in a bed next to an individual classified as an inpatient and inpatient surgeries with lower and lower expected lengths of stay. Technology and medical advancement, too, have changed the parameters of care. Woman can have simple mastectomies in the outpatient setting. Patients can have a knee replaced and not need inpatient medical care.

As a result, only the sickest of the sick require a hospital stay of more than a day or two. Now it seems hospitals focus more on when their patients will be discharged than when they will get better enough to go home. For physicians, the pressure is on to see more and more patients in a shorter and shorter time frame. Clinical managers seem to be less capable of (and less likely to) jump in to help when nurses are overloaded. And all the while, facility administrators continue to search for ways to not only keep their hospital doors open but to eke out some type of financial gain needed for facility, staffing, technology, and other improvements.

Which brings us to the current state of affairs.

Each patient in a bed is going to be reimbursed at either a bundled fee such as in a DRG payment, or a per diem rate as is the case with most commercial payers. But all patients are subject to the inevitable denials that seem to be so abundant lately, and all patients had better look as sick as possible in their coded and documented data to support the inpatient level of care.

Folks, that’s where you come in. Never underestimate the value of the work you do in your daily CDI efforts. Every medical record clarification, every clinical validation review, every CC/MCC captured, equated to a piece of data that could potentially affect the way our healthcare system delivers care to the most vulnerable among us, matters. And we all need to remember this.

Editor’s Note: Cathy Farraher, RN, MBA, CCM, CCDS, is a care manager at UC San Diego Health in California, and previously served as a co-chair for the CDI Practice Guidelines Committee for ACDIS, and as a co-leader for the Massachusetts ACDIS local chapter. Contact her at catarrina@gmail.com. Opinions expressed do not necessarily reflect those of HCPro, ACDIS, or any of its subsidiaries.