Ethical and compliant physician queries is the heart of clinical documentation improvement (CDI), and William Haik, MD, FACCP, CDIP, director of DRG Review, is concerned about an emerging ethical issue in the profession.
“The biggest problem is the problem list as best I can tell, and that’s going to be addressed in a soon-to-be future Practice Brief, using problem lists effectively,” Haik says of the electronic health record (EHR) feature that lists a patient’s most pressing ongoing conditions, which may or may not be relevant during a given inpatient or outpatient encounter.
Haik says that as Medicare Advantage relies on risk adjustment systems to reimburse hospitals and physicians, reporting illnesses from a patient’s problem list—based on their presence on the problem list—is becoming an ethical issue in CDI.
“They’re diligent and sometimes overly diligent reporting these additional diagnoses that are no longer relevant—not relevant to the current encounter. It can boost the severity of that patient, sometimes inappropriately, if the condition is no longer there,” Haik says. “Risk adjustment auditors look at these things. That becomes a difficult problem. The problem list is often the problem.”
Ethics Takes Center Stage at CDI Summit
Haik will be co-presenting at AHIMA’s CDI Summit with Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, independent consultant, on topics including an upcoming CDI Practice Brief AHIMA is producing with the Association of Clinical Documentation Improvement Specialists (ACDIS).
Bryant will lead the discussion on ethics in CDI, which will address how CDI specialists can avoid writing queries with non-leading language through the use of query templates.
“There have been some interesting issues surrounding CDI and HCCs of late,” Bryant says. “Due to the direct linkage of the clinical documentation to the coding and to reimbursement, there needs to be greater oversight of technology that is used in both CDI and coding, so we achieve compliant querying.”
To avoid this in CDI practice she says there really must be a quality assurance or review process for CDI, similar to that of coding, with auditing and monitoring. “Random and focused checking and reviewing of the queries and the query process should be in place within a CDI program or department,” Bryant adds.