The secret to CDI success: Teach physicians to document decision making

February 18, 2010

When CDI programs fail it’s typically due to a lack of physician involvement, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, an independent CDI specialist and reimbursement consultant.

“[CDI specialists] don’t do a good job of explaining why documentation is important and what’s in it for the physician,” he says.

To achieve support from physicians, CDI specialists should continually remind physicians that their documentation impacts more than the hospital—it affects their own practice as well.

So what does better documentation mean for the physician? A more comprehensive picture of the medical decision making that goes into evaluation and management of the patient, allowing the physician to bill a more appropriate (often higher-level) E/M code, Krauss says.

“The most important part of the E/M is the medical decision making—the doctor’s cognitive thought processes of what he’s thinking and what he’s going to order for workup,” Krauss says.

For example, if a physician orders gentamicin for a renal failure patient to treat his or her UTI, the physician has to be cognizant of the dosing as gentamicin is toxic to the kidneys. If the physician only documents acute renal insufficiency, a coder will report 593.9, an abnormal lab value which does not reflect the severity of the case and the physician’s complex thought processes that went into management of the patient.

A patient’s severity of illness is based on the number of diagnoses and management options. These are the building blocks of the complexity of the case. For example, billing a Level 4 E/M office visit requires that the physician is actively managing at least three problems. A helpful tip is to instruct physicians that they therefore need to document chronic conditions that they are monitoring or are concerned about from an outcomes perspective, Krauss says. And match up medications with diagnoses. For example, if a physician documents that he or she administered IV Lasix in a heart failure patient, ask them to document what he or she is treating in an effort to promote accurate, detailed, and specific documentation.

Note that commonly used documentation shortcuts are not always acceptable. For example, Medicare Administrative Contractor Trailblazer Health Enterprises, LLC published a notice in January entitled, “Three Magic Words? A Frowning Medicare Contractor’s Perspective,” which underscores that physicians cannot document the phrase “all others negative” as the basis for a complete review of symptoms. Instead, Trailblazer stated that a complete review of systems includes the following [emphasis added]:

Symptomatic systems must be separately documented and may not be documented simply as “positive” or “negative.”
Systems related to the presenting complaint/problem must be separately documented and may not be documented simply as “positive” or “negative.”
Asymptomatic systems not related to the presenting complaint/problem may be documented simply as “negative.”
A complete Review of Systems requires review of at least 10 systems – positive and/or negative.
The statement “all others are negative” is insufficient documentation of a complete Review of Systems for which at least 10 systems are not identified as having been reviewed.

For example, in a newly diagnosed diabetic patient who comes to the hospital complaining of dizziness, a physician may spend time asking about their diet, ordering an HgA1c/cholesterol panel, and changing the patient’s medications. However, if the physician only documents acute otitis media, a coder can only report 382.9 (unspecified otitis media), which, as Trailblazer notes in its article, is insufficient to report a level four office visit (99214):

"First, from a medical decision-making point of view, evaluation and management of an uncomplicated acute illness without systemic involvement does not ordinarily involve moderate medical decision-making (as judged by the E/M coding guidelines). Secondly, TrailBlazer would generally not find medical necessity for the work associated with such a service."

Share this Trailblazer guidance with your physicians, Krauss suggests. It will get them thinking of documenting multiple diagnoses and putting their thought patterns and treatments on paper, which will of course have the side benefit of helping your CDI efforts and the hospital.

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