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HM480 Ab103318 ch09
- 2. © 2020 AHIMA
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Clinical Documentation Integrity
• Definition
• Clinical documentation integrity is a process to facilitate
the accurate representation of a patient’s clinical status in
the patient health record.
• The most accurate and specific documentation possible is
then transformed into coded data.
- 3. © 2020 AHIMA
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CDI Goals
• Initiate concurrent and, as appropriate, retrospective
reviews of health records for conflicting, incomplete,
or nonspecific provider documentation
• Key organizational stakeholders are involved in setting
additional program goals
- 4. © 2020 AHIMA
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Operational Considerations
• Interdisciplinary team
• CDIP
• Alignment
• Record review
• Type of record
• Number of records
• Frequency of review
• Budget
• CDI staff training
• CDI med staff training
• CDI benchmarks
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Interdisciplinary Team
Single discipline model
• CDI team composed only of
one profession such as:
• Physicians
• Nurses
• HIM/coding
professionals
Hybrid staffing model
• Mix of professionals with
experience related to
documentation:
• Physicians
• Nurses
• HIM professionals
• Quality improvement
• Utilization
review/management
• Organizational training
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Clinical Documentation Improvement
Professional (CDIP) Certification
• CDIP was developed by AHIMA’s Commission on
Certification for Health Informatics and Information
Management (CCHIIM)
• Organizations seeking CDI staff may want to seek
candidates who have passed this exam indicating they
are:
• Knowledgeable and competent in clinical documentation
• Able to demonstrate competency in capturing
documentation necessary to fully communicate patients’
health status and conditions
• Ready for leadership roles
- 7. © 2020 AHIMA
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Alignment
• A CDI program may be housed in various areas of the
organization, such as:
• Corporate compliance
• Health information management
• Quality improvement
• Other area depending on organizational need
• CDI oversight committee
• Physician leadership (regardless of department)
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Record Review
• Reviewing every record concurrently typically is not
an achievable undertaking
• Selecting the priority areas is common
• Specific areas of service
• Selected patient care units
• Types of insurance
• High impact areas of documentation deficiency
• Payment/reimbursement is not the only consideration
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Record Review
• Items CDI staff seek include:
• Disease type
• Disease acuity
• Site specificity
• Disease stage
• Laterality
• Details needed to assign a combination code
• Completely missing documentation
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Diagnoses and procedures prone to
documentation gaps in the health record
Diabetes mellitus Neoplasms Heart disease
Injuries Pregnancy Pneumonia
Drug under- or overdose Respiratory/ventilators Ear disorders
Cerebral infarction Rehabilitation Eye disorders
Acute myocardial infarction Musculoskeletal conditions Atrial fibrillation
Procedures with contrasts Transfusions Malnutrition
Acute kidney failure/injury Sepsis Encephalopathy
Sources: Moczygemba and Fenton 2012; DeAlmeida et al. 2014; Hinkle-Azzara and
Carr 2014; AHIMA 2018a.
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Frequency of Review
• Each organization will set the expectation for
frequency of review
• Depending on individual factors this could be:
• Every day
• Every other day
• After admission and before discharge
• Other interval as determined by the CDI team
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Budget
• CDI program success is tied to access to appropriate
resources
• Budgets are tools for the planning and control
functions of management
• Number of records, frequency of review, composition
of CDI team, education methods, communication
needs, and tracking tools factor into CDI resource
needs
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CDI Staff Training
• Continuous education regarding documentation for
the following purposes:
• Regulatory
• Legal
• Coding
• External reporting
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Physician and Healthcare Provider Training
• Increase awareness of the multiple uses of
documentation and the importance of each
• Physician champion/advisor plays a large role
through peer education and communication
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Basic metrics for CDI program evaluation
Sources: AHIMA 2016a; Buttner et al. 2014; Gold and Kuehn 2011
• Record Review Rate
• Number of discharges reviewed divided by the number of discharges available for review
• Query Review Rate
• Number of records queried divided by the number of records reviewed
• Query Response Rate
• Number of responses divided by the number of records queried
• Query Agreement Rate
• Number of queries in which the physicians agree with the CDI staff divided by the number of
responses
• Co-morbidity and Complication (CC) and Major Co-morbidity and Complication Capture Rates
• Number of MS-DRGs with diagnosis codes for CC/MCC divided by number of total MS-DRGs
• Physician Clarification Impact Percentage
• The number of queries initiated by a CDI that had an impact on the DRG divided by the total
number of queries
• Severity Clarification Percentage
• The number of queries that resulted in a severity change divided by the total number of queries
- 16. © 2020 AHIMA
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Basic metrics for CDI program evaluation
(continued)
• CDI Productivity
• Each CDI professional's individual results in the given metrics
• Physician-specific Query Rate
• Each physician's individual results in the given metrics
• Physician Response Turnaround Time
• Amount of turnaround time between the initiation of the query and the physician response
• CDI/Coding Agreement
• Number of queries where the CDI team anticipated DRG matches the final coding assignment DRG divided by
total number of queries (a learning tool for both)
• Baseline Medical/Surgical Case Mix Index (CMI)
• Set at time of initial program assessment
• Actual CMI
• Medical and surgical—based on population CDI program reviews, such as Medicare only or all inpatient
discharges, etc. May want to exclude OB, newborn, psychiatry, rehabilitation, etc.
• Trending actual CMI to goal CMI
• Can break the trend into medical and surgical CMI, physician specialty/service line CMI. Most healthcare
facilities review CMI over time, both overall and by specialty
• DRG Proportions/Pairs
• Review Low/high DRGs and opportunities for DRG movement, such as from DRG 193-195, Simple Pneumonia, to
DRG 177-179, Respiratory Infections & Inflammations
Sources: AHIMA 2016a; Buttner et al. 2014; Gold and Kuehn 2011
- 17. © 2020 AHIMA
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Query Process
• Communication between the CDI team and
healthcare providers is key to success
• A query is a routine communication and education
tool used to advocate for complete and compliant
documentation
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Developing a Query
Situations where a query may be necessary include when
documentation:
• is conflicting, imprecise, incomplete, illegible, ambiguous
or inconsistent
• describes clinical indicators without a definitive
relationship to an underlying diagnosis
• includes clinical indicators, diagnostic evaluation, or
treatment not related to a specific condition or procedure
• provides a diagnosis without supporting clinical validation
• is unclear for present on admission indicator assignment
- 19. © 2020 AHIMA
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Developing a Query
• Include the reasoning and support for the query
• Determine if an open-ended or closed-ended
question is appropriate
• Goal is to receive the most accurate information,
not to lead the recipient to a desired response
- 20. © 2020 AHIMA
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Documentation of Queries
• Documentation as a result of the query should be
included in the patient record
• Each organization will determine if the actual query is
part of the patient record or retained in other
administrative records
• Policy needs to indicate where is it located and how
long it is retained
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Format of Queries
Uniform format guidelines:
• Patient name
• Admission date and time
• Account number
• Medical record number
• Date the query is initiated
• Contact information of the CDI reviewer
• Individualized diagnosis-specific information relevant to
the patient
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Query Operational Factors
• Where in the record queries are placed
• Process for notifying a physician that there is a query
• Standard procedures for how long a query is left open
or unanswered before following up
• What happens to an open query after the patient is
discharged
• Who will monitor the unanswered queries
• Feedback or corrective action to be taken and who
will undertake it
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Technology Considerations
• Capabilities of the electronic health record (EHR)
• A tool but not automatic documentation fix
• Computer assisted coding (CAC) process
• Developing technologies
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Supporting CDI
Success depends on the right people, processes, and
technologies to communicate:
• Many uses of clinical documentation
• Benefit of specific and accurate documentation
• Need for multiple stakeholder involvement
• Need for talented interdisciplinary CDI staff
• Required resources for success
• Need for predetermined policies and procedures for
record review and queries
• Metrics for building the business case for CDI initiatives
- 25. © 2020 AHIMA
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Coding Compliance
• Compliance means complying with rules, laws,
standards, or regulations
• Coded data is used for many purposes in the
healthcare system making compliance with
standards and expectations essential
- 26. © 2020 AHIMA
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Fraud and Abuse
• Fraudulent activities misrepresent the care that
actually took place
• Abuse is defined as an unintentional
misrepresentation
• Whether a person or organization knows or should
know applies when determining the difference
between fraud and abuse
- 27. © 2020 AHIMA
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Regulation
• Federal False Claims Act
• Deficit Reduction Act of 2005
• Health Insurance Portability and Accountability Act
(HIPAA)
• Important to keep current on developing regulations
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Exclusion from Government Programs
• Those found to be fraudulent or abusive can be
excluded from participation in Medicare or other
federal government programs
• Exclusion is significant as the government is the
largest purchaser and provider of services in the
country
- 31. © 2020 AHIMA
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OIG Guidance
The Office of the Inspector General (OIG) recommends:
• Written standards of conduct
• Written compliance policies and procedures
• Designation of a chief compliance officer
• Regular compliance training
• System to report compliance issues
• System to investigate and correct issues
• Regular audits to monitor compliance
- 32. © 2020 AHIMA
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OIG Workplan and Target Areas
• Each year the OIG publishes areas of interest for the
upcoming year online
• Target areas include:
• Billing for noncovered services
• Inaccurate claims
• Duplicate billing
• Upcoding
• Unbundling
• Overcoding
- 33. © 2020 AHIMA
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Coding Compliance Programs
The coding compliance plan should include the
following components:
• Policy statement regarding the commitment of the organization to
correctly assign and report codes
• The source of official coding guidelines used to direct code selection
• Identification of who is responsible for code selection
• The procedure to follow when clinical information is not clear or
specific enough to assign the correct code
• Specification of policies and procedures by care setting (ER, OP, IP)
• Applicable reporting requirements mandated by specific agencies,
including where payer-specific instructions can be found
- 34. © 2020 AHIMA
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Coding Compliance Programs
The coding compliance plan should include the
following components:
• Procedures for correction of inaccurate code assignments
• Areas of risk that have been identified through audits and monitoring, a
defined plan for audit and review, and corrective actions outlined for
identified problems
• Identification of essential coding resources available to and used by coding
professionals
• A process for coding new procedures or unusual diagnoses
• A procedure to identify any optional codes gathered for statistical purposes
by the facility and clarification of the appropriate use of external cause
codes
• Appropriate methods for resolving coding or documentation disputes with
physicians
- 35. © 2020 AHIMA
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Coding Compliance Programs
The coding compliance plan should include the
following components:
• A procedure for processing claim rejections
• A statement related to the fact that codes will not be assigned, modified, or
excluded solely for the purpose of maximizing reimbursement or avoiding
reduced payment. Also that clinical codes will not be revised merely
because of either physician or patient request to have the service in
question covered by insurance. If the initial code assignment did not reflect
actual services, codes may be revised on the basis of documentation.
• Statement on the use and reliance on encoding software; coding staff will
be skilled in the review of records and proper assignment of diagnostic and
procedural codes, not dependent or relying solely on coding software
• Medical records are analyzed and codes selected only with complete and
appropriate physician documentation available; official coding guidelines
state codes are not assigned without supporting documentation from the
provider and the entire record should be reviewed
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Key Clinical Documents
• Organizations should define what key clinical
documents are required for coding based on the care
setting and type of record
• Different settings and types may have different
requirements (inpatient, observation, emergency
department, and others)
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Coding Compliance Education
• Ongoing education is an integral part of preventing
fraud and abuse
• Sessions need to be documented
• Attendance should be a requirement of continued
employment
