Clinical Documentation Improvement Programs and Your Practice

Clinical Documentation Improvement (CDI) is missing from many ICD-10 plans for physicians. The hospitals are thinking about their CDI plan, but not about their employed physicians; and documentation begins and ends with the physician. So if the hospital's clinical documentation is not sufficient, the place to start is not just in the hospital but also the physician practice.

I recommend that every medical practice whether independent or part of a hospital group develop a CDI protocol. What does that really mean? Hospitals can purchase software to assist with data mining to determine what records to review and develop an automated query process. But what can the physician practice do for CDI? CDI will be so important with ICD-10 to ensure your practice is staying on top of the clinical documentation and accurate ICD-10 coding.

One of the interesting things I hear when I speak to physicians is, "We got paid, it must be right." They falsely assume every paid claim is accurate and are not really certain what they need to document to get paid appropriately. What about their billing and coding policies? I ran across a large hospital-owned physician practice which was not one of my clients that was billing preventive visits and problematic visits for every patient they wrote a prescription for. The practice said it forced every patient who scheduled a preventive visit to sign a document that they understood if the physician discussed anything about their medical condition including the need for renewal of prescriptions, a level 3 (99213) visit would be billed in addition to the preventive medicine visit. Is this method of coding and billing correct? I don’t believe it is. Where was administration in all this? How could the coding and billing rules be so misinterpreted and who pays the price?

When I questioned a couple of the physicians in the group they both told me administration told them to do this. A lot of coding and billing errors similar to this could be eliminated with a CDI program in place in the medical practice.

CDI 101

What does CDI really mean? CDI refers to the process of improving documentation to better reflect the severity of the patient encounter. Imagine if physicians were paid based on severity of illness versus relative value units (RVUs)? Do you think their reimbursement would increase or decrease? I would bet it would decrease significantly if payment was based on the current documented diagnoses. The ICD-9 set justifies medical necessity for services rendered and assists with supporting medical necessity for the E&M service level reported. ICD-10 will change or modify how practitioners document and code patient encounters. Clinical documentation is not "all about the money."

Clinical documentation services many purposes including:

• Adherence to medical practice and standards of care
• Medical necessity (diagnosis codes)
• Quality and outcomes measures
• Measures of efficiency and effectiveness
• Medicolegal purposes
• Adherence to Joint Commission standards and other requirements
• Basis and support of reimbursement for services rendered

The fact is when documentation is insufficient, incomplete, or incorrect, insurance companies, RACs, MICs, and others can take back payment with fines and penalties in some instances. By developing a solid CDI program the risks can be significantly reduced. Because documentation issues will be at the forefront with ICD-10 it is important that your ICD-10 steering committee take a good look in developing a CDI program.

ICD-9 to ICD-10 Examples
Pre-eclampsia antepartum with gestational diabetes
ICD-10 clinical documentation will need to specify 1.) trimester; 2.) pre-existing or gestational diabetes, diabetes type; and 3.) other maternal diseases complicating pregnancy (i.e., anemia, obesity, alcohol use, smoking, mental, digestive disorders)

You notice in both of these examples that with a little more detail in the documentation, accurate diagnosis coding can be achieved.

Deborah Grider, CDIP, CPC, CPC-I, CPC-H, CPC-P, CPMA, CEMC, CCS-P, is a senior manager for revenue cycle at Blue & Co. LLC. Grider is a nationally recognized author of American Medical Association Publications, including "Principles of ICD-9-CM," "Coding with Modifiers," "Medical Record Auditor," and "Principles of ICD-10-CM and the ICD-10-CM Workbook." She is a healthcare consultant with over 32 years of coding, billing, practice management, and Health Information Management experience. E-mail her here.