Serenity CDI: The essential piece to today’s clinical operations

By E.S. Damalie, MD, FACHE, FHFMA, RHIA, CCDS, CDIP, CCS

The U.S. healthcare system, while one of the most dynamic healthcare environments in the world, is nevertheless riddled with constant changes. Hospital operations have shifted into value-of-care versus the old focus on volume-of-care, bringing with it the need for significant understanding of clinical operations. Only those with strategically groomed healthcare leaders focused on these clinical operations will excel in the current environment.

The healthcare system accounts for nearly 18% of the gross domestic product in 2016 (CMS, 2017); a significant chunk compared to other developed countries, yet the outcomes/indices are not very convincing (The Commonwealth Fund, 2015). According to CMS National Health Expenditure Report for 2016, the US Healthcare system has witnessed spending increases in both the type of service or product (i.e., hospital care, physician and clinical services, prescription drugs, other professional services, home health, nursing care, etc.) and sources of funds (i.e. Medicare, Medicaid, private health insurance and out of pocket spending) making the case more for the adoption of measures that can stop the cost of healthcare from spiraling out of control.

Most of these measures force healthcare providers to implement strategies that address quality outcomes, patient satisfaction, and coordination of care. The shift to the value of care (pay for performance) could potentially result in a slashing of hospital reimbursement of up to 6% (CMS, 2017; QualityNet, 2017). Many hospitals are caught unawares as the years used to measure their performance may be a couple of years behind the current year; in effect, they do not have the opportunity to correct what is already done. If CDI is equated to good clinical care it becomes a key ingredient essential to the success of today’s hospital operation.

To the patient and family, good clinical documentation should contain all the information about their health conditions that can facilitate the care even if they find themselves in a different hospital. For the physician, good clinical documentation should paint the relevant clinical picture of the patient, address their medical needs and ensure continuity of care. In the case of the hospital or healthcare entity, good clinical documentation should address medical necessity concerns, meet regulatory requirements so that they get paid for the resources utilized and promote a culture of a satisfied client (patient). In case of regulatory agencies, good clinical documentation should be compliant with all applicable laws/regulations and address the necessity of services provided at the right setting.

A good CDI program is holistic in nature and addresses all interested parties, setting the organization on the path of success. The old concept of CDI focused on volume and reimbursement is long-gone. Today, although volume may still be significant, the quality of that volume and what is done with that volume is supreme.

Painting the true picture of what is wrong with the patients seen at the facility will address all the quality concerns of the patient and enable both the physician and hospital to take credit for the good work performed. In doing so, hospitals stand in a unique position not only to avert the potential cuts brought about by the paradigm shift in today’s healthcare terrain but they also place themselves in a better position to be the model and the preferred destination for their satisfied patients. There is also the additional benefit of minimizing their denials and staying in compliance with other regulatory audits.

The healthcare terrain keeps changing and hospital operation is becoming more of a clinical operation.

Editor’s note: Damalie, a physician and CDI specialist, is currently affiliated with Serenity CDI+ Solutions, which offers CDI, appeals and denials management, coding and auditing, and other revenue cycle services. Currently a fellow of both the America College of Healthcare Executives and Healthcare Financial Management Association, he also serves on the ACDIS CDI Practice Guidelines Committee, and as chairman of the Certification Committee for the Southern California Chapter of HFMA. The opinions expressed do not necessarily reflect those of ACDIS or its advisory board. Contact him at serenityCDIplus@gmail.com.