I guess I have gotten complacent, thinking that people had finally gotten the message that Clinical Documentation Improvement (CDI) needs to focus on achieving a complete and accurate medical record and not simply focus on increasing reimbursement. Recent events remind us all that we are not there yet.
Just recently, a well-publicized report announced, “Justice Department Joins Lawsuit Alleging Massive Medicare Fraud…” In this report, two whistleblower complaints accuse a major insurer of gaming the Medicare Advantage payment system. The cases could result in repayments (with damages) in excess of one billion dollars.
The regulations are clear. In the Federal Register (Volume 79, No. 7, January 10, 2014, page 2000), the Centers for Medicare & Medicaid Services (CMS) state that for Medicare Advantage (MA), “Any medical record reviews conducted by an MA organization must be designed to determine the accuracy of diagnoses,” and, “…medical record reviews conducted by an MA organization cannot be designed only to identify diagnoses that would trigger additional payments by CMS to the MA organization; and medical record review methodologies must be designed to identify errors in diagnoses submitted to CMS as risk adjustment data, regardless of whether the data errors would result in positive or negative payment adjustments.”
The Association of Clinical Documentation Improvement Specialists (ACDIS) Code of Ethics addresses this issue quite directly, stating: “Clinical documentation improvement professionals shall … use queries as a communication tool to improve the quality of health record documentation, not to inappropriately increase reimbursement or misrepresent quality of care,” and, “Clinical documentation improvement professionals shall not … promote patterns of retrospective documentation to avoid suspension of, or increases to, reimbursement.”
The American Hospital Information Management Association (AHIMA) Ethical Standards for Clinical Documentation Improvement (CDI) Professionals (2016) also addresses this issue, stating: “The focus of CDI programs should be on the quality and integrity of the documentation regardless of financial impact. Documentation must support the care provided as well as the health status of the patient. Any information not supported by the patient’s condition for the current encounter, must not be introduced solely to increase financial reimbursement.”
Still, some suppliers of CDI services promise to increase revenues based on their analysis of Case Mix Index, and the percentage of Diagnosis-Related Groups (DRGs) billed that reflect complications and comorbidities (CC and MCC capture rates). Their training often encourages simply finding a CC or MCC and moving on to the next chart, rather creating a quality record of each admission. This focus on reimbursement carries the risk of compromising accepted practices of CDI training and queries. AHIMA’s “Guidelines for Achieving a Compliant Query Practice (2016 Update),” state, “A query should … not indicate the impact on reimbursement. A leading query is one that … directs a provider to a specific diagnosis or procedure.”
Beyond the ethical considerations are the impacts that low quality and spotty reviews will have on pay-for-performance measures in the coming years. Current directions in healthcare finances show a growing emphasis on the use of pay-for-performance methodologies, with estimates as high as 60 percent of reimbursements going this way by 2018. Short-term focus on documentation that only drives reimbursement will do a grave disservice to hospitals by failing to document all of the factors that impact risk and severity of illness.
It is time that the field of Clinical Documentation Improvement takes a stand on ethical practices, and no longer tolerates the single-minded pursuit of reimbursement. In this context, I am reminded of the words of Winston Churchill to the House of Commons (May 2, 1935 on the eve of WWII), who said: “When the situation was manageable it was neglected, and now that it is thoroughly out of hand we apply too late the remedies which then might have effected a cure.”
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