Guest Post: The rules of the game have changed, and CDI must re-engineer itself or fail

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

With the advent of Recovery Auditors, CERT reviews, and MAC audits, the landscape of CDI as we know it has changed. CDI specialists’ roles must change to adapt with these changing times.

What does this mean?

Physician queries to clarify diagnoses are the old model. It no longer holds up in today’s environment of increased medical record scrutiny.

The rules have changed, and if you’re not changing you’re contributing to denials in your facility. Conclusionary statements by the physician without the clinical facts and the doctors’ thought processes will result in medical necessity denials and other take-backs by CMS contractors and payers.

So what is the role of CDI in this new environment?

It’s to capture diagnoses, of course, but also to explain the rationale for care, the reason why the patient was admitted to the hospital. It’s also to explain why the patient needs to be in the hospital every day. That means asking the physician to provide:

• A continuous record of all diagnoses treated and monitored
• Documentation of patient status each and every day
• Information regarding whether the patient’s clinical conditions under active management are improving, worsening, or responding slowly to therapy
• Documentation of changes in patient management and treatment
• Ongoing plans for discharge

(Incidentally, these elements will help the physician with his or her evaluation and management (E/M) billing. More on this in a minute.)

This means reviewing a record more than once. It is more than simply “optimizing” a DRG and moving on; more than what I refer to as the “grab and run” approach to CDI. This leads to increased revenue and improved case mix index (CMI) today that unnecessarily contributes to increased denials and take backs six months later.

If a physician treats a patient for sepsis, over time does the sepsis improve, or worsen? Does it stabilize, or is it not responding to therapy? Rather than just getting the doctor to write “sepsis,” this is the type of detail needed in the medical record, and that CDI should be working to achieve.  If you focus on the money and don’t focus on the underlying principles of good documentation, the money won’t be there for the hospital or the physician after auditors scrutinize the record.

Focus instead on demonstrating medical necessity for the hospital and the doctor, and the continuity of care in the discharge summary. Forget CCs and MCCs—just get all the diagnoses that are relevant to the stay that impact the doctor’s medical decision-making. The record will speak for itself, and the DRG will take care of itself.

This article on the Part A CMS payer National Government Services website clearly defines good documentation practices. This can serve as a standard for which CDI specialists should strive.

This level of documentation requires a total mindset change of what CDI is about. The old model of CC/MCC capture does not promote the CDI profession the way it should be, which is, as its name implies, improved clinical documentation.

The old model results in increased denials in today’s environment as well. I argue that denied inpatient stays, denied CCs and MCCs, and downcoded DRGs should count against the positive impacts CDI makes on case mix. It’s time to re-engineer CDI and refocus our efforts in the face of this new and changing environment.

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