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Clinical Documentation Improvement and the Clinical Truth

Publish Date
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February 20, 2019

There was a time, not so long ago, that when a physician assigned a diagnosis to a patient, no one questioned the validity of their medical knowledge. As a matter of fact, I imagine such an inquiry would have been laughable. But, the evolution of electronic medical records, documentation requirements and the need to appease auditors have led to the onslaught of the query frenzy.

Today, a physician documents a diagnosis and the questions begin. Can you please specify laterality? Can you please provide the acuity and severity? Is there a significance between diagnosis A and diagnosis B? Physicians are put into an uncomfortable position, thinking that their medical knowledge and judgment are being questioned. Thus, the visible annoyance they have with CDI and coders.

One important factor that has been missed in physician education is helping them understand the WHY? Why are we still seeing an increase in denial rates even after all the queries have been appropriately answered? This really comes down one thing – the need to provide clinical support for every diagnosis in the chart.

The WHY behind queries can be answered rather simply. There must be clinical support for every diagnosis in the chart.

There comes a point for physicians where the frustration caused by the query process outweighs the benefits derived by fulfilling the purpose of the process. That leads to an erosion in the physicians’ belief that CDI programs are helpful to the goal of ensuring high-quality clinical documentation.

In Pursuit of “The Clinical Truth” via CDI

One of the biggest problems CDI faces is the documentation and coding, of a diagnosis without ensuring that it is clinically supported and can be defended. Understandably, there is a coding guideline that states, “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”[1] However, given the rise of clinical validation denials, educating physicians and coders that capturing the patient’s true clinical picture is more important than capturing a code because it drives the DRG to a higher level.

Not only does “the clinical truth” stand as the defense in denials, but it tells the patient’s story so that throughout the continuum of care providers are given the appropriate information to help improve outcomes instead of wasting time having to research and fill in missing pieces of patient information.

When looking at a record from a CDI perspective, the entire story is imperative in determining whether a diagnosis is present, has been ruled out, or if a query for more information is necessary. For instance, a patient comes into the ED with a UTI, leukocytosis, and fever. I have seen coders who, at this point, automatically go for sepsis without regard for the medical knowledge of the physician treating the patient who says that this patient simply has a UTI. With this thought process, every patient that darkens the doors with an infection, leukocytosis, and fever will be queried for sepsis. How about the patient who presents in diabetic ketoacidosis and the physician documents that the patient is experiencing pseudo-hyponatremia due to hyperglycemia? Is it appropriate to code pseudo-hyponatremia as hyponatremia to capture the CC?

When physicians document diagnoses and include the clinical findings within the documentation, it helps CDI understand the etiology, the disease process, the treatment plan, and what documentation is necessary to tell the most accurate story of the patient. Clear, concise documentation also helps the coder determine what should be coded. It is easy to pick and choose clinical indicators and query for diagnoses that are simply not there. This is sometimes where coders cross that fine line between what the physician documents and what the coder interprets that documentation to mean. Clarification queries are a great tool to help fill in the documentation gaps and obtain the necessary information within the record. However, queries are not intended to serve as the main documentation education tool or for “leading” a physician to a specific diagnosis by using vague clinical indicators.

The basic purpose of clinical documentation improvement is simple – CDI is meant to enhance medical data collection to improve care quality and maximize claims reimbursement revenue.

CDI Has a Responsibility to Ensure the Clinical Truth Is Evident in Every Record

Diagnoses must be clinically supported so that denials can be defended. Physician education that is provided must be done so in a way that encourages a change in behavior with the focus being more on the patient and less on the money. By ensuring the clinical truth is evident in every record, we begin a chain of positive outcomes such as:

  • Improvement of physician quality scores
  • Appropriate reimbursement and quality incentives for facilities
  • Accurate coding
  • Fewer denials
  • More time for CDI departments to focus on in-depth reviews and proper education

Most importantly, improved quality of patient care is evident when the clinical truth is presented. By directing our focus to the entirety of the patient’s story we are returning to the basic purpose of clinical documentation improvement – the enhancement of medical data collection to maximize claims reimbursement revenue and improve care quality. By being more concerned with capturing the truth and less concerned with capturing MCC’s and CC’s, we can initiate change in the way CDI is viewed and the positive impact that CDI can have on the care of the patient.

Learn about The Importance of Capturing the True Clinical Picture and why The True Clinical Picture Begins with a Solid Foundation of Documentation.

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