Amber Malone-Wright – What is Clinical Documentation Improvement?

This episode is the second installment about Clinical Documentation and Coding. Today, we have a conversation about Clinical Documentation Improvement with Amber Malone-Wright, Director of Clinical Documentation Integrity at CHESS Health Solutions.

I want to pick your brain about clinical documentation improvement also known as CDI. So tell me amber what is CDI all about?

Well Thomas, I think the main message about CDI is around quality initiatives. Most people who ask providers why good clinical documentation is necessary, many of them are going to say that it’s important for the communication to other providers about the continuity of care. Physicians generally understand the need to make documentation legible, timely, complete, and clear and you know with electronic medical records a lot of that is resolved. They also understand that documentation is a legal health record. They understand the common phrase – if you didn’t document it, it didn’t get done. CDI programs have increased significantly over the past ten years and are predominantly used in the inpatient hospital setting. But now this is expanding into the ambulatory and provider office setting due you value-based care and contract changes. The key is to really just engage providers to correlate how clinical documentation provides an opportunity to demonstrate the quality of care that was provided during an office visit. The American Health Information Management Association or AHIMA really says it best. They say the message to physicians should be: simple good clinical documentation will improve communication, increase recognition of comorbid conditions that are responsive to treatment, and validate the care that was provided, and show compliance with quality and safety guidelines.

Why should a provider change their documentation?

So physicians are taught to ask why as part of a diagnostic training that they went through and the need to understand the reason for a change in clinical documentation in order to fully embrace the concept. So if a provider challenges a CDI recommendation, it’s an opportunity to explain why CDI is necessary. Explain the concept around whether it’s MSDRG for inpatient or value-based care contracts and how they’re designed to increase reimbursement for care of complex patients. It’s also important to explain the severity or the illness or risk or mortality score that’s derived from the codable diagnosis codes. It’s also important that providers understand the process of audits and denials and financial impact. Not only for hospitals but the outpatient office visits as well. Documenting all of the chronic conditions that are known for the patients that affect the care and treatment for that patient impact the medical decision making by the provider and can also impact the level of evaluation and management services.

Amber, tell me how a provider can implement CDI into their workflow?

Electronic medical record technology has really improved the ability for medical records to be legible and timely. Physicians generally use structured templates to input documentation or they can dictate in a standard progress note format. But sometimes, the benefits of the electronic documentation are not always great. Sometimes there are significant challenges with electronic documentation, such as copy and pasting documentation, which can increase the risk of audits including outdated problem lists and then the inability for providers to find the correct diagnosis code in a drop-down selection. It’s important to remember that providers are not trained in coding, yet many providers now know the codes that are important for their billing. If the provider chooses a nonspecific diagnosis code to include in the medical record, it could potentially make it more difficult for someone to code the case with a more specific diagnosis code. The EHR creates the opportunity to really assist the providers with clinical documentation and often provide a means of great communication between a CDI specialist or a coder and the physician. Whenever possible, building clinical documentation systems that make it easy for providers to select a codable diagnosis is best practice. For example, the diagnosis of chronic kidney disease is common when providers document and code this condition, but it’s oftentimes unspecified. However oftentimes there are other indicators in the medical records such as an abnormal lab or a note from a specialist or hospital visit that may indicate a specific stage of chronic kidney disease. This can easily be queried back to the provider utilizing the electronic medical record and clinical other references to specify the stage in the documentation. CDI should also be vetted through a compliance department to ensure integrity without leading the provider to a specific diagnosis. It’s also important to educate providers on how to choose the appropriate diagnosis from the electronic medical record drop down selections.

And what’s the best way to query a provider?

So, the ideal solution would be electronic queries from the electronic medical record as this is easily accessible to the provider and often links the patients health record. When querying a provider it’s really important to make sure the query is not leaning but that the communication is clear. Queries can be verbal they can be paper or electronic and should be monitored and tracked for responses and engagement. Physicians will have a greater response to queries when they’re evidence based and clinically evident in the medical record. Queries should be presented to the provider in the context to actually clarify the documentation to ensure compliance. CDI programs can also use clinical guidelines to assist with identifying diagnoses that are not documented but are clinically indicated in the documentation. So for example, you might see a patient whose documented as diabetes uncontrolled and they have an A1C of 9.0 in the medical record which could indicate that possibly this patient has uncontrolled diabetes. Queries should be clear and concise. They should contain the clinical indicators, present only facts to the physicians, and also be compliant. The Association of Clinical Documentation Integrity Specialist or ACDIS is a great resource that is available to review with when starting a CDI or query workflow program. Written queries can be formatted as open-ended multiple choice or yes or no but again it can never be leading for a physician to a specific diagnosis code. Organizations are free to determine the specifics around their query process and compliant practice requires that all queries either be a permanent part of the medical record or be retrievable in a business record for tracking and monitoring purposes.

So Amber, tell me, how can an organization get started successfully with a good CDI program.

Well Thomas, I think the first thing is really conducting a documentation and coding review process of what is documented in the medical record. Identifying documentation discrepancies or deficiencies can help identify opportunities for education and improvement. I think it’s important to take into consideration with the ACDIS and AHIMA must have already established around query guidelines and rules and regulations to make sure that they’re compliant. And then also working with their compliance or legal department to make sure that they’re not leading their physicians and that they have good policies and procedures in place.

Outstanding stuff! Amber Malone-Wright, thank you for joining us today on the Move to Value Podcast!

Thank you