Guest Post: The new CDI thought process: The vision to see beyond immediate results

by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS

Too many CDI specialists live for the immediate satisfaction of today. Their primary focus is upon getting a diagnosis documented in the record once and then moving on to the next chart, looking to secure another diagnosis and score a “win,” as measured by number of queries generated and number of queries positively responded to by physicians.

The medical record must clearly articulate the physician’s clinical rationale and judgment in support of conclusive diagnostic statements. These statements alone, however, are no longer sufficient in support of diagnosis code assignment from both the physician and hospital perspective, not to mention establishment of medical necessity for inpatient admission as well as physician evaluation and management (E/M) assignment. The clinical facts of the case explicitly documented in the record, supported by the physician’s thoughts and updated plan of care, serve to best reflect the patient’s true clinical condition, acuity, and ICD-9-CM diagnosis code assignment.

If you get this added documentation in the chart, it deprives third-party reviewers of their widely pervasive stand to refute a once documented diagnosis on the basis of its clinical significance and recouping money from the hospital. This is I what I coin the “vision to see beyond immediate results.”

What do I mean by this statement? Let me demonstrate with an example.

What is stronger documentation: A physician responding to a multiple-choice query and writing the term “neuropathy” once in the record, or documenting as follows?

Neuropathy related to prior oxaliplatin dosing. Symptoms have not dissipated despite using a vitamin B complex. This may be a limiting factor in choosing future chemotherapy agents. If the chemo related neuropathy continues, consider stopping the current chemo regimen altogether and see if a short chemo holiday improves the patient’s severe neuropathic pain and then, perhaps, begin a new regimen. My immediate concern right now is to get the patient over the hurdle of her relentless pain in the legs and arms, then discharge the patient and see how she does, bring her back into the office for evaluation in a week and hopefully start a new chemo regimen.

This example, taken from an actual chart, shows the diagnosis of neuropathy with clinical support beyond the typical diagnostic conclusion statement. While neuropathy, aside from acute infectious polyneuritis, is not considered a “CC,” the level of documentation including discussion of the physician’s clinical judgment, thought processes, and medical decision making goes a long way in supporting the medical necessity for inpatient admission and continued stay in the hospital. Helping physicians incorporate explicit documentation of clinical facts undoubtedly adds value to our roles and responsibilities as CDI specialists. Yet this benefit is not immediately measurable in results the hospital’s chief financial officer can equate to in terms of revenue and return on investment for CDI staff.

Nevertheless, even if a condition is not a CC, we should still be seeking specificity from the physician—especially with ICD-10-CM/PCS implementation on the horizon. If we take the time to work with the doctors today on documentation that impacts their payment—i.e., reflects their medical decision-making and ensures medical necessity for procedures and services—they’ll be willing to help us tomorrow.

Keep in mind that taking the extra time with a doctor today might result in a short term loss of productivity. Maybe you only get to 22 charts instead of 25. But you’ll also be ready for when ICD-10 comes, and your physicians will have bought into your CDI program.

Speaking of ICD-10, here is an excellent link comparing ICD-9 to ICD-10 for several commonly-used codes. Use this to focus your CDI efforts on specific code sets: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2013-Transmittals-Items/R1199OTN.html.

In short, get the extra specificity today. Strive for clinical support and documentation of all diagnoses, regardless of whether or not something is a CC with such efforts you will find the “vision to see beyond immediate results.”

Editor’s note: At the time of this article's original release, Krauss was Executive Director of the Foundation for Physician Documentation Integrity.