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March 19, 2007

What Clinical Documentation Improvement Is—And What It’s Not
By Robert S. Gold, MD
For The Record
Vol. 19 No. 6 P. 8

You have been hearing and reading about various initiatives that are being called documentation improvement. You’ve been hearing about the goals of increasing hospital revenues and increasing CC (complications and comorbidity) capture rate so you can obtain a higher-weighted diagnosis-related group (DRG). In the past year or two, you have been hearing that this helps profiles and physicians.


I submit that this does not represent clinical documentation improvement. This is hospital revenue enhancement, plain and simple. A knowledgeable HIM professional and myself came to this conclusion several years ago. And people who believe they will flourish with processes like those previously mentioned are sorely mistaken.

Yes, there was a time when the overall emphasis within hospital revenue cycle teams was to improve the case mix index (CMI) and CC capture rate purely for the purpose of changing patterns of income under Medicare and other DRG payers. This was because hospitals didn’t know how to deal with the evolution of the Prospective Payment System. Particular issues came to light that, specifically, physicians were not trained in a uniform language for entries into the medical record. And they indeed did, and still do, often provide the wrong semantic terminology to certain concepts in healthcare that can lead to the inability to arrive at the proper code sets or determine a DRG assignment. They have had, and still have, that problem in identifying the principal diagnosis and secondary diagnoses, whether those secondaries meet the definition of CC.

Hospitals that were transitioning between modified fee for service and the DRG payment system were losing their shorts. As a result, companies developed systems to help case managers bombard the medical staff with notes to get them to provide words that can lead to ICD codes that would enhance the DRG under these circumstances.

That type of program had its benefits, but, over the last five to 10 years, it’s had its day. The future is now, and hospitals are ill-prepared for the conversion to severity-adjusted DRG payment; physicians are equally ill-prepared for severity-adjusted payments, and almost nobody is prepared for profiles and quality measures.

Unless, that is, you have been providing a true clinical documentation improvement initiative—and that’s not what a revenue enhancement program provides.

Various promotional material, articles, and ads claim “We have increased hospital revenues by over a million dollars” or “We have increased CMI by 0.1 for our clients.” No doubt the federal government is looking at these hospitals when people tout that kind of “success.”

What It Is
A true clinical documentation improvement program must be a medical staff initiative that will eventually result in doctors who make entries into the medical record with words that paint the true picture of their patients so the HIM department can paint the exact same picture in codes. The medical staff has to take ownership of this initiative and not be the targets of overworked case managers who hand out notes that are unintelligible and burdensome to physicians in verbiage they don’t understand because it’s HIM speak and totally irrelevant to a particular patient’s case.

In my audioseminars, I try to apply clinical direction to all the educational pieces. I’ve gotten comments from attendees such as, “We don’t need this kind of information to assign codes. We need more coding rules in the presentation; this was too clinical!” Fortunately, those people are few in number, and most attendees appreciate my goal of helping them understand the clinical aspects of the diagnoses and procedures to which they have to assign codes.

Proper painting of the picture that describes the patient in words and subsequent proper reflection of the same picture in codes has amazing results—that is clinical documentation improvement. A program that gets you there has plenty of benefits, among them:

• It leads to the precise assignment of DRGs. It doesn’t matter whether it’s one with a higher or lower weight. When the proper words lead to the proper codes, it leads to the proper DRG—the one that the case deserves, and the one that will be impervious to oversight review.

• It leads to the precise severity of illness (SOI) level and risk of mortality (ROM) level. Regardless of the software package being used now or in the future, if the correct codes are assigned across the board (and the coders must make sure that the top 16 most severe codes are in the top 16 positions on the UB-04 by manually placing them there, if necessary), you will get the proper SOI and ROM. You must assign the codes for all the pertinent conditions documented in the medical record.

• It leads to the proper severity-adjusted CMI, which will be the driving force of payments in the future for hospitals, nursing homes, long-term acute care facilities, and just about everything else. Certainly, the feds have been working with severity-adjusted payments for physicians for approximately five years, and if your doctors don’t know how to express severity appropriately, they will lose.

• It leads to the proper reflection of the risk-adjusted mortality index (RAMI)—the denominator of that fraction that determines your hospital’s profiles and your physicians’ profiles. If your program leads to a principal diagnosis and a secondary that is a CC and goes no further, your profiles are miserable because of the physicians’ underdocumenting and your undercoding. This is an issue in places where productivity and reimbursement are the HIM department,’s goals with resultant detriment of the hospital’s quality statistics. Sure, you’ll get more dollars in now, but you won’t have any patients tomorrow. Your case mix will be great, but you won’t have any cases because your statistics show that you kill people.

• It leads to proper charge capture for inpatient and outpatient procedures that are diagnosis-driven.

• It leads to decreased interventions by the insurance companies that are looking for justification of that additional day on the intensive care unit.

• It leads to appropriate evaluation and management services professional billing by the medical staff and recognition that the physicians don’t have to undercode anymore to stay under the radar—they can bill a level 5 consult or a critical care code—because their notes properly reflect the severity and critical aspects of their patients that will withstand the review of outside authorities (as long as they count bullets, too—for now).

• It leads to consultants who are happy to receive requests for help from other physicians because, when they see the record already established, they know the consulting physician knows what else is wrong with the patient, so they can concentrate on their specific area rather than having to waste valuable time and start from scratch.

• It leads to happy compliance officers who realize the notes in the medical record will provide whatever words and clinical justification they need to withstand an Office of Inspector General review.

• It leads to a content legal department that realizes a medical record can really stand on its own in defense of a frivolous lawsuit.

• It results in employees/healthcare professionals who, when you provide them with their individual improvements in quality statistics and other measures of success (because they couldn’t care less about hospital CMI unless they own the hospital), will ask, “Hey, I have this patient. How can I better express what’s wrong with him?”

• It leads to coders who can ask a valuable, clinical retrospective question rather than something in HIM jargon that a physician cannot fathom.

• It leads to overall success, regardless of what the payers do in the future, regardless of how the rules change. Other initiatives can’t say that.

The process has to be physician-driven, not targeted. It has to be clinically driven, not financially driven. It has to have the dedication of administration such that resources are provided to ensure success, and there’s no skimping on personnel or needed supplies. It has to be pervasive and not competitive, involving everyone in a mutually beneficial success.

— Robert S. Gold, MD, is CEO and founder of DCBA, Inc.

RAMI = Risk-Adjusted Mortality Index
This is the ratio of observed mortality rate to severity-adjusted (or risk-adjusted) expected mortality rate. It can be measured for the entire hospital, a diagnosis-related group, or a physician. The word index means “one.” When your fraction = 1, you’re right where you should be—that is, just as many people are dying as are expected to die. If your ratio is above one, your observed rate is higher than expected, and you look bad. When your ratio is under one, your observed rate is less than expected, and you look good.

Observed rate is driven by the care delivered by the staff at your hospital. Severity-adjusted expected rate depends on ICD codes being assigned that demonstrate severity of illness and risk of mortality. This is where proper documentation and complete, accurate, and specific coding drives the ship. You may measure length-of-stay index, cost-per-patient index, or any variable using the same concept of the ratio.