Clinical documentation is the information a person responsible for a patient’s medical care enters in a medical record, which is a repository for an individual’s health information. The entries contained in the medical record may be authored by a physician, dentist, chiropractor, or other healthcare professional. Regulations, accreditation requirements, internal policies, and other rules may define who is allowed to document in the medical record in specific cases.
Clinical documentation improvement (CDI) is the process of reviewing medical record documentation for completeness and accuracy. CDI includes a review of disease process, diagnostic findings, and what documentation might be missing. A CDI specialist often has both clinical and medical coding backgrounds. Bridging the gap between clinical documentation and accurate coding drives CDI programs.
While reports from laboratory tests, diagnostic tests, and consultations with specialists may also be housed in a patient’s medical record, “clinical documentation” in the context of CDI generally refers to the entries made by a provider or clinical staff member who is responsible for the patient’s care during a face-to-face visit.
CDI programs have been a part of healthcare since long before the term was uttered. However, they got a boost in popularity around 2007 when the Centers for Medicare & Medicaid Services (CMS) implemented Medicare Severity Diagnosis Related Groups (MS-DRGs). MS-DRG is a payment model used for reimbursement under Medicare’s Inpatient Prospective Payment System (IPPS). Hospitals realized that accurate and thorough diagnosis code reporting increased reimbursement and reduced compliance risks with IPPS. As a result, CDI programs were organized so that a team of nurses could concurrently review the inpatient medical record documentation and query a provider concerning anything ambiguous or not complete prior to claim submission. This practice resulted in more accurate billing for the facility, and the CDI trend took hold.
While CDI may have gotten its start in the inpatient environment, outpatient providers have recognized the benefit and started programs, as well. The natures of inpatient and outpatient CDI programs vary, but they share a goal of increasing the accuracy of clinical documentation and coding.
A clinical documentation improvement program is a process designed and implemented with the purpose of achieving accurate and thorough medical record documentation.
Why are CDI programs needed? In many ways, the use of electronic health record (EHR) systems has eased the burden on providers and hospitals of navigating the administrative duties surrounding patient care and claim submission. However, the responsibility of medical record documentation — the entry of clinical information concerning care rendered to a patient — will always remain with the medical provider. To help providers succeed in this task, a CDI specialist is responsible for reviewing a patient’s medical record to ensure documentation reflects the specificity of current conditions to allow for accurate coding of the patient’s health status.
CDI can improve the accuracy of coding and billing for inpatient facilities, which will result in more accurate reimbursement. The financial impact of an inpatient CDI program is not limited to initial payment of claims, though. Improper claim submissions resulting from poor documentation can result in unfavorable audits, which could require facilities to pay a fine, return money erroneously collected from payers, or both. Consequently, the role of CDI in claims processing in healthcare facilities includes both increasing the accuracy of initial reimbursement and preventing expensive consequences from reviews by authorities.
Hospitals are familiar with and subject to various types of audits. To guarantee their facility’s documentation withstands auditor scrutiny, a CDI specialist needs to be knowledgeable about the federal regulations regarding fraud, abuse, and compliance, as well as payer requirements for clinical presentations of diseases. For instance, the department of Health and Human Services (HHS) tasks the Office of Inspector General (OIG) with identifying, by way of the OIG’s Work Plan, incidences of fraud, waste, and abuse within medical claims submitted to the federal government.
In one example of poor documentation practices in healthcare facilities — and documentation not supporting coding — an OIG audit was released in July 2020 that determined hospitals overbilled Medicare $1 billion by incorrectly assigning severe malnutrition diagnosis codes to inpatient hospital claims. In 200 claims reviewed in this audit, 164 contained severe malnutrition diagnosis codes when they should have had other forms of malnutrition or no malnutrition diagnosis codes at all. OIG recommended that Medicare collect the overpayments from providers where possible. A CDI specialist can help stop this sort of improper reporting and confirm patients have accurate diagnoses in the medical record by reviewing documentation and training providers and coders on the documentation required to support malnutrition diagnoses and codes.
Audits on the OIG’s radar change from year to year. CDI specialists and others working in healthcare should review the OIG Work Plan regularly to keep up to date.
Preventing unsupported diagnoses from being reported on a claim is one benefit of inpatient CDI programs. But ensuring all conditions that are clinically supported get reported is equally important because of how inpatient facility reimbursement works. To fully grasp how a CDI program can be successful for an inpatient facility from a financial perspective, it is necessary to understand Medicare’s DRG payment system. Many non-Medicare payers use an adaptation of this DRG payment system, as well.
Diagnosis related groups (DRGs) are just that: groupings of a patient’s diagnoses that are related and impact care during an inpatient stay. The patient’s principal diagnosis and up to 24 secondary diagnoses, including comorbid conditions (CC) or major comorbid conditions (MCC), determine the DRG assignment. The scenario below demonstrates the connection between diagnoses, DRGs, and reimbursement.
Scenario 1: Example of diagnosis grouping in an inpatient facility
A 52-year-old male patient was admitted to an acute care hospital with a diagnosis of chronic obstructive pulmonary disease (COPD) with acute exacerbation. After a four-day stay receiving treatment, the patient was discharged. If a claim had been submitted with this single condition, the DRG assignment would have looked like this: