Clinical Documentation Improvement in 2016 – The New Normal
Over the past several years, Clinical Documentation Improvement (CDI) Programs have proliferated. In fact, 81% of hospitals have reported having a CDI Program according to a 2015 study by the Advisory Board. The emphasis on documentation has been driven by internal financial performance goals, government mandates (ICD-10) and programs (see MACRA article here), and an ever increasing expectation that provider documentation is substantiated by clinical evidence.
AHIMA’s Practice Briefs, which are viewed as the ‘Gold Standard’ for query policy guidance, introduced the concept of “clinical validation” in their most recent practice brief “Guidelines for Achieving a Compliant Query Practice” published in February 2013. This Practice Brief set the precedent for an expanded scope for provider queries. See excerpt from the AHIMA Practice Brief below:
Guidelines for Achieving a Compliant Query Practice When and How to Query
The generation of a query should be considered when the health record documentation:
- Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
- Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
- Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
- Provides a diagnosis without underlying clinical validation
- Is unclear for present on admission indicator assignment
The fourth bullet, ‘Provides a diagnosis without underlying clinical validation’ is the key addition to this Practice Brief. This guidance is a significant evolution from the previous advice noted in the 2008 AHIMA Practice Brief, “Managing an Effective Query Process”. In the brief, AHIMA stated that “queries should not be used to question a provider’s clinical judgment, but rather to clarify documentation when it fails to meet any of the five criteria listed above—legibility, completeness, clarity, consistency, or precision. A query may not be appropriate simply because the clinical information or clinical picture does not appear to support the documentation of a condition or procedure”.
Although the advice from 2008 does not directly conflict with the guidance from 2013, there is a shift from more cautious language (“a query may not be appropriate simply because information or the clinical picture does not appear to support the documentation of a condition or procedure” to more direct/proactive language (“Query when documentation provides a diagnosis without underlying clinical validation”).
Gone are the days when physician documentation is not questioned. In the past, if a provider documented a diagnosis, it was coded (and generally not denied). Now, as indicated by the practice brief language, coders and CDI specialists are expected to query providers for the purposes of clinical validation or they run the risk of payer denials. In 2016, diagnoses and procedures must be supported by strong clinical documentation full of clinical indicators and precise language. It is critical that CDI programs also evolve with the times to ensure they meet the more rigid and expansive regulatory and compliance requirements today.
Best Practices: A few things to consider when completing a query
- Always use complete sentences: Complete sentences are easier to read and comprehend.
- Include brief supporting detail (pertinent positives or negatives): Pertinent positives may support query opportunities related to patient acuity, severity of illness, or risk of mortality. Pertinent negatives help support the rationale for why a query is being placed. For example: Documentation of acute MI with normal troponin levels.
- Do not copy and paste content from the medical record: The medical record is lengthy and often includes extraneous information not needed to support patient acuity, severity of illness, or risk of mortality.
- Do not use abbreviations: Abbreviations are more difficult to read and comprehend.
- Only use acronyms if they are used in everyday conversation: Acronyms that are used in everyday conversation (like “COPD”) are easy to read and comprehend; otherwise they are more difficult to read and comprehend.
- “Guidelines for Achieving a Compliant Query Practice.” Journal of AHIMA 84, no.2 (February 2013): 50-53.
- “Managing an Effective Query Process” Journal of AHIMA 79, no.10 (October 2008): 83-88.
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