By Tammy Combs, RN, MSN, CCS, CCDS, CDIP
Clinical documentation integrity (CDI) is a profession that has, in the past, been viewed as just a revenue-seeking program—but that’s not the full story. CDI programs that promote high-quality documentation not only support the capture of appropriate reimbursement but also the quality of care provided to the patient by ensuring all the information within the health record is of high quality and supports informed medical decision-making.
It is vital for CDI professionals to be aware of the documentation elements that have an impact in the setting in which they work. This information is needed to recognize the return on investment when developing and managing a CDI program. However, this should not lead the CDI professional to silo their health record reviews into only clarifying for documentation elements that impact reimbursement, but rather focus on high-quality documentation that accurately tells the patient story.
CDI and the Healthcare Continuum
Patients flow through numerous care settings within the vast healthcare matrix, including inpatient and outpatient areas. Inpatient care is reserved for a higher intensity of care that is delivered in a hospital setting while outpatient care requires a lower level of intensity and may be delivered either within or outside of a hospital. The setting in which a patient receives care is determined by the patient’s physician.1
Within each of the areas there are various care-focused groups. The inpatient setting can be broken into different hospital units based on the patient’s diagnosis or procedure that was performed. The outpatient setting can be even more diverse, including multiple care locations such as the emergency department (ED), hospital observation care, physician clinics, home health services, and ambulatory surgery.
The importance of high-quality clinical documentation across the continuum of healthcare can be recognized in the analogy of a cruise. Just as patients rely on numerous providers and healthcare professionals to maintain a good state of health, passengers on a cruise ship rely on numerous crew members to ensure they have smooth sailing and stay on course. The anchor on a cruise ship can hold the ship in a certain location or be raised when the ship is sailing. Sometimes patients will be at one location for their care and the documentation is the anchor that provides the information needed for the healthcare teams to stay on course.
When patients are discharged or complete a provider visit, they may see another provider in a separate location and setting. The new provider will rely on the documentation from the previous encounter to guide their medical decision-making. Each episode of care should include documentation that clearly supports each episode of care. Like the anchor, the documentation supports a comprehensive view of the care provided for any single encounter, it may stop when the patient’s encounter or admission is over but there is a clear record for each encounter. With this assortment of care settings, it would be detrimental to the patient if a provider only considered the care that was provided in one setting to guide their medical decision-making.
Clinical Impact of CDI
CDI professionals should be aware of the impact of clinical documentation across the continuum of care. The impact seen throughout the different settings will vary. For example, in the inpatient setting some payers will classify diagnoses into diagnosis related groups (DRGs). These DRGs have relative weights that capture the complexity of care and are used for reimbursement purposes. DRGs also impact the case mix index (CMI), which is the average of all the DRG relative weights to capture the patient’s disease burden. In the outpatient setting some payers will classify diseases into hierarchical condition categories (HCCs); these also have weights associated with them, which can be used to calculate a risk adjustment score.
Even though CMI and the risk adjustment score are two different measurements, they both reflect the patient’s disease burden. The elements within the documentation that impact the CMI and risk adjustment will vary. A CDI professional should be aware of all the elements of high-quality clinical documentation so the patient’s disease burden is accurately captured in all healthcare settings. There are seven characteristics that should be seen within clinical documentation for it to be recognized as high quality.
These characteristics include documentation that is:2
These characteristics can be applied across all healthcare settings.
A characteristic of high-quality clinical documentation is documentation that is precise. Precise documentation is accurate, exact, and strictly defines the patient’s conditions.3 An example of a diagnosis that should be assessed for precision is the diagnosis of congestive heart failure (CHF). In the outpatient setting the documentation of CHF is enough information for the condition to fall into an HCC. However, documentation of CHF alone in the inpatient setting would not impact the DRG relative weight unless the acuity and type of heart failure is noted in the documentation. This is a good example of a time when documentation may impact the patient’s disease burden representation in one setting but not another. If the outpatient CDI professional focuses on recognizing high-quality documentation and not just elements needed for HCC capture, they can better validate when all documentation meets the characteristic to be of high-quality, which would then accurately represent the disease burden across all settings.
High-quality documentation is also vital to medical decision-making. Continuing with the CHF diagnosis example, CHF is a chronic condition that can influence many aspects of a patient’s care. The treatment of CHF is decided based on the type of heart failure and if the patient has any other underlying conditions.4 The documentation of underlying conditions would be considered complete and reliable documentation. Complete documentation is that which includes maximum content; reliable documentation is trustworthy and safe.5
- US Centers for Medicare and Medicaid Services (CMS). Inpatient hospital care. https://www.medicare.gov/coverage/inpatient-hospital-care.
- Hess, Pamela Carroll. Clinical Documentation Improvement: Principles and Practice. Chicago: AHIMA Press, 2017.
- Johns Hopkins Medicine. Congestive Heart Failure: Prevention, Treatment and Research. https://www.hopkinsmedicine.org/health/conditions-and-diseases/congestive-heart-failure-prevention-treatment-and-research.
- Hess, Pamela Carroll. Clinical Documentation Improvement: Principles and Practice.
Tammy Combs (Tammy.Combs@ahima.org) is director, HIM practice excellence, CDI/nurse planner, at AHIMA.