During the last 10 years, hospitals, along with companies in every other industry in the country, have undertaken steps to improve revenues in order to remain viable. One key issue traditionally has been making sure that revenues from Medicare become as optimal as possible. Other organizations have taken alternative approaches, such as positioning themselves for competitive marketing through development of statistical evidence illustrating quality delivery of healthcare regardless of payer, letting revenues go where they may. Some put more emphasis on the needs of the future than the needs driven by today’s bottom line.

All hospitals recognize that, without a physician’s justified order (one accompanied by a symptom or diagnosis) for delivery of a healthcare service, there is no billing for any service whatsoever. Whether a physician is asking for a blood chemistry analysis, a cardiac stress test or admission for appendectomy, there is no billing without an appropriate diagnosis. So the medical staff’s function as it pertains to the medical record of a patient, whether an inpatient or outpatient, has been recognized as an imperative when it comes to establishing medical necessity.

Hospitals that have looked to the future – and survival, by means of evidence-based practice demonstrating excellence in some, if not all, areas of healthcare delivery and patient satisfaction – also have turned to the medical staff in one way or another.

In the past, physicians have been pleaded with, cajoled, even wined and dined regarding cooperation with chart management. Physicians have been lectured by health information management staff, lawyers, utilization review nurses and business consultants in an attempt to encourage cooperation.

One of the methods that many have adopted is the institution of a clinical documentation program – some call it documentation management, some call it documentation integrity, but most call it documentation improvement. Whatever the name, the goal is to provide interaction with physicians treating patients in the hospital, offering support that will aid them in the documentation of diagnostic information in the chart. This diagnostic information is intended to validate billing, or quality profiles, or medical necessity for an inpatient stay, or testing, or any number of criteria. The goal is righteous. The methodology embraced by some can be tenuous or based on bad decisions, if not grossly inappropriate.

Reacting to a long history of inappropriate hospital billing practices emerging since the institution of the IPPS program, the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG), state professional review organizations or quality improvement organizations, and Recovery Audit Contractors have had a field day retrieving funds inappropriately paid. This trend started long before CDI programs even existed, so one certainly cannot point fingers at this new industry adjunct as being the culprit. 

However, regardless of the high ethics intended by most personnel now performing CDI functions in healthcare, some bad practices have developed out of bad advice – and some inappropriate billing has evolved from bad definitions of diseases issued by the National Centers for Health Statistics and subsequent advice on how to use the codes for these diseases. And the RACs are loving it.

A CDI program is supposed to help physicians tell patients’ stories in the medical record, in words that will lead to ICD-9-CM or ICD-10-CM codes that tell the same stories. It is supposed to be above reimbursement as the ultimate goal, but rather for the sole benefit of the patient and the patient’s medical record. If you don’t know what’s wrong with the patient – if everyone doesn’t know what’s wrong with the patient – how can you treat the patient properly? How can you bill for treatment properly? How can you demonstrate excellence in care?

Let’s discuss some of the issues that can lead even the most well-meaning program down the wrong path. Let’s learn some of the erroneous definitions and how to protect ourselves from falling into traps that stand in our way. Let’s learn how to use evidence-based medical practice to lead to evidence-based CDI initiatives that will be purely RAC-proof. When the excellence of your medical staff and the support of the people who provide hands-on care of patients can be proven statistically, you’ll do well. If you’re in the newspaper due to allegations of improper billing, your reputation suffers – and business suffers.

And nowadays, realistically, healthcare is a business.

About the Author

Robert S. Gold, MD, is a nationally known physician, responsible for having championed Clinical Documentation with his peers and hospital organizations. Dr. Gold is a cofounder and the CEO for DCBA, Inc., a consulting firm that concentrates on development of Clinical Documentation Improvement (CDI) programs that aid in proper reimbursement

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