Medical record documentation determines the reimbursement paid to physicians and hospitals, but so much more than money is at stake. After the documentation is translated into the alpha-numeric codes submitted in claims, the data are analyzed to generate results on quality and clinical outcome measures, in addition to payments.
For example, codes reflecting severity of illness and risk of mortality are used to risk-adjust data in order to avoid penalizing clinicians who care for sicker patients. This levels the playing field for all clinicians. Therefore, clinician documentation must translate into precise codes that will fully reflect illness severity and mortality risk, intensity of services provided, and resources expended in caring for patients.
However, since coding rules and terminology differ from common clinical language, there is a risk that the clinical reality will get lost in translation. This is where clinical documentation improvement (CDI) programs come in.
A CDI program is a comprehensive, multi-disciplinary, hospital-wide effort to incorporate the terminology needed to accurately translate a patient's condition into precise codes. Today, more than 80% of U.S. acute care hospitals have established CDI programs, the objectives of which are listed in Table 1.
The key players on a CDI team are clinicians, clinical documentation specialists (CDS), and inpatient coders. Other members include those in nutrition service, wound care, care management, and the lab. Clinicians in this case include any health care professional licensed and credentialed to diagnose and treat patients, including doctors of medicine (MD), doctors of osteopathic medicine (DO), doctors of podiatric medicine (DPM), residents, nurse practitioners, physician assistants, nurse anesthetists, and others.
Clinicians play the most important part in CDI, since they are intimately familiar with the patient and the conditions being treated. Their documentation drives and controls everything that happens subsequently. Clinician CDI participation has 3 components: awareness, competence, and collaboration (see Table 2).
The clinical documentation specialist's role is, through medical record review, to capture pertinent clinician documentation while the patient is in the hospital. The next step, if needed, is to submit a request (query) to clinicians for clarification or additional documentation that would permit assignment of a more precise code. A CDS should conduct verbal discussions with clinicians whenever possible for more effective communication.
Collaboration and exchange of information between a CDS and an inpatient coder are necessary to ensure that the clinician documentation is actually translated into the codes that reflect the patient's condition. The CDS also facilitates clinician education by giving brief presentations at medical staff meetings and conferences as well as by having direct conversations with clinicians.
Inpatient coders must not only collaborate with the CDS but must also be trained in the clinical terminology and diagnostic criteria most often encountered in the CDI process. There are almost always opportunities to improve code selection, sequencing, and application of coding guidelines.
Coders typically report through the medical records department to the hospital's chief financial officer, and a CDS frequently reports through care management to nursing. For an effective CDI program, managers must ensure close collaboration, consensus processes and definitions, and shared values and objectives. Too often divisiveness and conflict prevail. As an alternative, a unified reporting structure for both coders and CDS can mitigate this dilemma.
Best practices require that a CDI physician advisor, often a hospitalist, support the CDI program. The role of a fully engaged CDI advisor is outlined in Table 3.
In summary, a clinical documentation improvement program is a comprehensive, multi-disciplinary effort that includes the medical staff, clinical documentation specialists, inpatient coders, and CDI physician advisors. It is designed to ensure documentation of diagnostic and procedural terminology needed for accurate translation of clinical work into the precise codes that best describe the severity of illness of patients and the complexity of care provided to them.