Guest Post: Flipping applies only to the art of burger grilling
by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS
A recent ACDIS blog post by Kimberly Richert, RN, CCDS, entitled “A nurse is more than just a nurse” raises an interesting point that Clinical Documentation Improvement (CDI) specialists must remain cognizant of and true to as part of our mission to improve and effect change in clinical documentation. I call your attention to Kimberly’s assertion that the CDI specialist is not just a “chart hound” and that a CDI specialist that excels in documentation improvement demonstrates and applies proficient critical and clinical thinking skills.
The role of CDI specialists
The CDI profession arose from the recognition that clinical documentation in the health record was in a woefully inadequate state. Some type of proactive strategy was needed to address and correct deficiencies in clinical documentation that were negatively impacting accurate reporting of patient severity of illness, risk of morbidity and mortality, and case mix.
While the role of the CDI specialist is constantly evolving as the amount and level of complexity in data reporting based upon clinical documentation expands, there are certain elements of CDI that must be considered as fundamentally basic and rudimentary to the role. Integral to a CDI specialists’ role are the following:
- concurrently reviewing medical records from a clinical perspective
- developing a key understanding and awareness of clinical medicine
- assimilating clinical data available associated with diagnostic work-up and patient history
- taking into account the physician’s medical decision-making as evidenced by physician directed patient work-up
- putting all these components of chart review together and effectively crafting a compliant clinical query in the interest of complete and accurate clinical documentation.
Unfortunately, there appears to be a movement away from the fundamental basics of CDI, a movement that has caught the eye of the MedPac Commission this month to recommend a continued downward adjustment to the annual market- basket update on the basis of documentation and coding increases not associated with actual increases in clinical patient acuity and case-mix index. What is this movement? Cases are being reviewed by CDI specialists with the intent of “maximizing” or “optimizing” the MS-DRG.
While obviously all clinical documentation improvement programs must be financially self-sustaining, focusing upon achieving the maximum reimbursement has a tendency to “warp” one’s clinical and critical thinking skills and thought processes. Take the following clinical example that I recently pointed out in a Justcoding.com article:
Patient admitted through the emergency room with significant dehydration, hypotension, and acute renal failure with oliguria requiring fluid resuscitation and strict measurement of ins and outs. Final diagnoses provided by physician in last progress note and reinforced in discharge summary were:
- hypotension,
- acute renal failure, and
- dehydration.
Clinical documentation improvement specialists proposed as part of the follow-up DRG process to assign the hypotension as the principal diagnosis.
From a reimbursement standpoint, one would not doubt the appropriateness of assigning the hypotension as the principal diagnosis. However, as a nurse utilizing one’s clinical knowledge and understanding and appreciation for clinical disease processes, it is quite evident that hypotension in this instance is an integral part of the dehydration resulting acute renal failure, and as such does not meet the definition of principal diagnosis (i.e., the chief reason after study that occasioned the admission to the hospital).
Burger flipping
So why did I reference “burger flipping” in the title of this post? What is happening is there appears to be a trend towards some CDI specialists reviewing records with a tendency towards losing sight of the clinical thought process and critical skills required to identify the hidden clinical agenda requiring documentation clarification. When one loses sight of these critical thinking skills supporting the drive for clinical accuracy in documentation and coding, the end result is the flipping mentality: Look at the diagnoses at hand, review the MS-DRG hierarchy, and “flip” the principal diagnosis for optimal reimbursement. What a very dangerous and hazardous precedent.
Don’t get caught in the flipping mentality and stay focused upon the clinical skill sets and clinical knowledge inherent in your practice of clinical documentation improvement. Leave the burger flipping for backyard barbeques, parties, and burger joints.
Editor's note: Krauss, at the time of this article's release, was Executive Director of the Foundation for Physician Documentation Integrity.