Tip: CDI growth depends on record review expansion

In a recent CDI Talk conversation the discussion centered around whether CDI professionals are working with case management staff on the documentation of medical necessity. The overall consensus was that the establishment of medical necessity for inpatient admission rests with the case management (CM) and utilization review (UR) staff of the hospital.

 

In my opinion, failing to work collaborative with CM/UR teams fails to do justice to our profession—that is strengthening clinical documentation throughout the patient’s continuum of care as an integral part of the hospital’s effective revenue cycle process. Everyone involved—from the admitting physician to the CM/UR staff, from the CDI specialists to the HIM team—has a strong incentive in avoiding medical necessity denials in the name of the fiscal health and integrity of their institution.

 

Our focus as CDI specialists has been (until now) primarily on obtaining “buzz words” related to selecting principal and secondary diagnoses. While important, this focus fails to capitalize on the role we can certainly play in solidifying the medical necessity for inpatient admission.

 

Short-term focus on improving clinical documentation, episodically, one record at a time, without including record reviews for medical necessity as an integral part of CDI efforts, is a pointed lesson in futility. Consider the number of potential cases in a given month where the Recovery Auditors (formerly Recovery Audit Contractors [RAC]) and other Medicare contractors eventually come to the conclusion that the patient stay “should have been observation” due to lack of established medical necessity, this despite the fact CDI efforts resulted in a shift of the principal diagnosis of chest pain to “GERD” or altered mental status to “drug induced delirium.”

 

After all, what good does it do to capture documentation of diagnoses if auditors later refute the medical necessity of the admission and deny the claim?

 

Editor’s Note: Krauss is a manager at Accretive Health in Chicago and an independent consultant based in Madison, WI. Read this article in its entirety on the ACDIS Blog.