jpitsikoulis100Clinical Documentation Improvement (CDI) can be defined as the practice of ensuring that all service, treatment and evaluation of patient care is captured and reflected accurately in physician documentation.


In essence, Clinical Documentation Specialists (CDIs) assist physicians in communicating their practices of medicine to third-party payers, regulatory bodies and other interested parties. While the goals of a CDI program can vary depending on focus, hospitals typically concentrate on improving clinical documentation in order to demonstrate severity of illness, which in many cases will result in an increase in the reimbursement associated with the severity assigned.


Hundreds of hospitals have implemented CDI programs, and many others are continuing to implement new programs or re-implement old ones that have lost their way, resulting in diminished returns on investment. The importance of clinical documentation cannot be overstated when it comes to accurate coding and appropriate reimbursement. With the demand for more clinically detailed coding under MS-DRGs, and certainly the future under ICD-10, clinical documentation improvement programs will not be an option, but a requirement.


But what about the here and now when it comes to mitigating your RAC denial risk due to questionable clinical documentation? It is no mystery that the RACs are focusing in on this as grounds for claims denial.


According to the our findings, more than half of the RAC denials appealed by providers in more than 25 hospitals evaluated were related to questionable documentation – and surprisingly, these hospitals had established CDI programs.
How can that be, if the clinical documentation improvement programs in these hospitals were effective? Gathered through interviews, effectiveness audits and informational findings, here are a few of the recurring reasons contributing to some of these RAC denials.

Focus on the CDI Programs’ Primary Objectives

Some CDI programs were focused on enhancing clinical documentation for the purpose of improving reimbursement. It was reported that while CDI staff review cases for clinical documentation completeness, due to competing priorities and time constraints they focus on increasing reimbursement charts as a priority. If time permits, they review other cases to determine if clinical documentation was consistent and concise.


Clinical documentation programs represent a significant expense. They are expensive to implement and they are expensive to maintain. While some of the hospitals mentioned understood the financial risk of not reviewing medical records from a RAC risk perspective, budgetary constraints just did not allow them to hire additional CDI specialists or invest in other requisite attributes of a program.


Some CDI specialists believe the responsibility of ensuring the existence of clinical documentation to support code assignments is the responsibility of the HIM coding department. While there is validity in that statement, it is ultimately the facility’s responsibility to ensure that the clinical documentation and coding is appropriate.

How to Mitigate RAC Denial Risk

One thing we know for certain is that we are seeing RAC denials due to incomplete and inconsistent clinical documentation practices.


To help mitigate future risk of RAC denials due to insufficient clinical documentation, start by evaluating the following:


  • Your current CDI program, to determine if it is focused on revenue enhancement as well as risk RAC mitigation.
  • Your HIM department’s coding quality review process, for the same reasons.
  • Your RAC’s and other payers’ denials, for trends in denials due to insufficient documentation.


Reviewing your facility’s daily activities, documentation of these activities and outcome reports will demonstrate the trends for increases and decreases in reimbursement. If all of the cases exhibit increases, you could have an unbalanced approach to improving clinical documentation and coding accuracy.


About the Author


John Pitsikoulis, RHIA, is the Vice President of Consulting and is based in Wayne, PA Corporate office. He is the national practice leader for the firm’s Clinical Documentation Improvement, Auditing, Education and Recovery Audit Contractors (RAC) & Regulatory services. John has a background that combines his unique experience advising clients on compliance, financial and clinical operational issues. Prior to joining Precyse, John served as the engagement director for numerous national engagements involving litigation advisory assistance including OIG investigations, Corporate Integrity Agreement engagements, and independent review organization reviews engagements. Specifically, John has led CIA/IRO engagements for observation/short stay encounters, acute Inpatient Rehabilitation, and DRG upcoding.

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