Guest Post: A CDI specialist’s response to fears of fraud

by Juanita B. Seel, RN, CCDS

I am supervisor of a documentation integrity program at a leading teaching hospital in South Carolina. Our program has been in existence for seven years. I want to reply to the article in the September 2011 edition of Today’s Hospitalist titled “Beware of Leading Queries: Some documentation efforts could lead to fraud,” by Kenji Asakura, MD, and Erik Ordal, MBA, and inform readers that not all documentation improvement programs are like the one this article describes.

My staff consists of RNs who are not coders, have not been trained in coding, and only review the record from the clinical perspective. We align diagnoses, treatments, and clinical data (labs, radiological studies, and other studies) to the diagnoses documented in the medical record to accurately reflect the severity of illness (SOI) and risk of mortality (ROM). When the documentation is unclear or inconsistent, we ask for the physician’s opinion to help ensure the validation of diagnoses that captures the most appropriate SOI/ROM levels. We query physicians in an attempt to link the “medical diagnoses” with the “coding language” to capture the most appropriate diagnosis and ensure quality data collection.

Frequently physician documentation lacks the clarity to reflect the true SOI/ROM levels. For example, in coding, a diagnosis of urosepsis equates to a simple urinary tract infection (UTI) that typically does not accurately reflect the physician’s intention and treatment, or the patient’s actual condition. When queried, most physicians say that, to them, urosepsis indicates the patient was septic related to a UTI.

Unless the physician specifically documents “the patient is septic due to a related UTI,” however, the coder can only assign the code for UTI due to coding rules and regulations. This code will not capture the intensity of service provided to the patient (i.e., IV antibiotics, frequent vital signs, increased nursing care, etc.). Conversely, if the physician documents sepsis related to UTI and the patient meets criteria for sepsis, this documentation will capture all the increased resources used to treat the patient.

CDI programs should be quality driven, not financially driven.  With changes in healthcare and reimbursement the documentation in the medical record must be clinically sound and written in appropriate terminology. CDI programs are not here to tell physicians how to practice medicine—physicians know how to practice medicine and most do it superbly. Rather, CDI programs exist to provide that link between physicians and the coding world and to ensure the quality data is documented and recorded appropriately. Our program looks at the integrity and consistency of the documentation in the medical record.

The most successful and accurate documentation improvement programs abide by the standards and guidance of the American Health Information Management Association (AHIMA) and the code of ethics of the Association of Clinical Documentation Improvement Specialists (ACDIS). We are professionals and have worked hard to established standards to guide clinical documentation improvement (CDI) programs.

CDI professionals should review and evaluate physician documentation as well as provide education to ensure physicians know how this information is translated into reporting quality data for all healthcare providers, physicians, and hospitals. Information in the medical record is now used for so many other areas than just coding, including:

• Benchmarking
• Recording of quality care for the patient
• Future care for the patient
• Research
• Public reporting such as HealthGrades.com

Physicians must document well enough for this information to  be captured through the coding of the medical record. This is the only way hospitals can track the above mentioned important items.

The average consumer can find hospital quality data on the Internet, so the data must reflect true and accurate information about the quality of patient care in any facility. This is captured only through accurate and concise documentation of the medical record. CDI programs should not be seen as a method of physician coercion or fraud. The aim of CDI programs is to analyze physician documentation and align the diagnosis with the treatment provided and the intensity of service rendered to ensure the documentation is appropriate to capture what happened to a given patient.

I am a Certified Clinical Documentation Specialist (CCDS). I am a RN. I am not a coder. I exist to assist the physician with appropriate documentation and to ensure the hospital has quality data for reporting. Sometimes, my job results in increased re-imbursement and sometimes it does not. It is important for the hospitals to receive appropriate recognition for the quality service and quality care given to its patients.

Editor's note: Seel, at the time of this article's original release, was supervisor of documentation integrity at Greenville (SC) Hospital Center University Medical Center is a member of the 2012 ACDIS national conference committee and vice president of the recently formed South Carolina ACDIS Chapter.