This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.
By Chinedum Mogbo MBBS, MS HIM, RHIA, CCDS, CDIP, CCS
When clinical documentation improvement (CDI) programs first started appearing, the goal was generally to ensure the capture of Complications and Comorbidities (CCs)/Major Complications and Comorbidities (MCCs) or Severity of Illness (SOI) that would impact the Diagnosis Related Group (DRG), thereby ensuring that the best DRG was assigned to achieve the appropriate reimbursement. The use of queries has played a significant role in capturing CCs and MCCs concurrently and retrospectively (pre-bill).
Over time and with the advent of various quality reporting systems, the focus of CDI has grown to include not only the capture of CCs and MCCs but also the capture of quality indicators such as Patient Safety Indicators (PSIs), which are of great value in collecting data for quality metrics reporting.
Queries play a significant role in enabling providers to document better and gives them the ability to “think in ink,” putting to paper/computer the possible diagnosis/condition they have in mind, when treating patients. Queries also serve as an educational tool in CDI. It helps to assess areas of documentation that need improvement and provides the ability to gather such data, which can be utilized in providing focused education to providers on accurate documentation. The query response rate and time can also serve as a benchmark to assess the level of acceptance and impact of the CDI program.
While the use of queries is an essential tool in a CDI program, it is possible for an undue emphasis on “query rate” to lead to misuse of this important tool. For example, the idea of pressuring CDI professionals to meet a 30-40 percent query rate without first tailoring the query rate to specific needs by taking into account the program’s maturity and dynamics is problematic. What is the basis for this query rate?
While I am not against vendors that market “CDI improvement” tools, I do find it unnerving that some of these tools are marketed under the virtue of their ability to increase the number of queries. This information is often presented to CDI management, CEOs, and CFOs with beautiful color-coded charts that show how the tool can lead to an increase in reimbursement. But a closer look will often reveal that these query-generating tools, if not utilized with caution, can lead to a loss of the true essence of a CDI program: physician education and documentation integrity that reflects better patient care and outcomes.
For a new CDI program, I would expect a high query rate. But our goal as CDI professionals is not just to query our providers—it is also to educate them on the importance of accurate documentation and the rippling effect on data being reported for utilization review, case management, reimbursement, quality reporting, and research purposes. As a CDI program matures and acceptance grows, there should be a decline in the query rate as a result of effective education efforts.
There are organizations that set the query rate from the corporate level without truly understanding the dynamics in various facilities. Decision makers should consider the dynamics (e.g., patient type, service type, physician awareness/education of CDI, facility size, electronic health record tools) in their various facilities prior to enforcing query rate metrics. When you have a fixed query rate without the opportunity to adjust as the environment of the program changes, you run the risk of “over-querying,” with CDI professioanls forced to query for anything and everything in order to meet the pre-set metrics. Such circumstances ultimately lead to inappropriate/unnecessary queries and unnecessarily holding up accounts for billing.
There are various real-time electronic tools that can prompt better documentation and thus have the ability to reduce the number of queries placed while improving documentation and allowing CDI professionals to focus on providing education to members of the healthcare team. The interaction between CDI and the healthcare team can also have an impact on utilization review and case management.
I am a strong advocate of a CDI program with less queries, but I also know that achieving this is an uphill task. When we focus on query rates, we lose the value of the impact that CDI can have on a program. I believe more emphasis should be placed on interacting with and educating providers and other members of the healthcare team to ensure that our patients are well taken care of and that documentation is truly reflective of the severity of illness, quality, and level of care provided.
A decline in queries should of course come with improved quality and financial metrics of a facility/health system. The goal is to ensure that queries placed are relevant and necessary, and will improve documentation integrity.
The questions we need to ask are:
- Are we querying to meet metrics or are we utilizing queries as an educational tool with the eventual goal of reducing the number of queries generated?
- Are we open to adjusting our query rate benchmark (if any) based on our facility dynamics?
- What parameters can we use to ensure that if we do set a query rate, that it will be reflective of our individual CDI programs?
Chinedum Mogbo is manager, CDI for Tenet Health’s California Market.