CDI Programs Generate Denials!

CDI (Clinical Documentation Improvement) program queries are a part of ensuring accurate clinical documentation, but often they result in denials for a variety of reasons. Here's why CDI program queries often lead to denials:

1. Lack of Clarity in the Query: If a query is not clearly worded, it can create confusion, leading to a denial. For example, if the query is ambiguous or does not directly ask for a specific clarification, it might not provide enough information for the healthcare provider to act upon.
2. Failure to Follow Documentation Guidelines: If the query does not follow the standardized guidelines for clinical documentation or is outside the scope of acceptable clinical coding practices, it may result in a denial.
3. Inappropriate or Unnecessary Queries: Sometimes, CDI teams might generate queries that are not needed based on the patient's clinical status or documented history. Insurers or payers may deny claims if they believe the query is irrelevant to the case or does not significantly affect coding and billing.
4. Provider's Response or Lack of Response: If the healthcare provider does not respond to a CDI query in a timely manner, or if the response does not align with the query, the insurer might deny the claim due to insufficient or unclear documentation.
5. Querying for Unsupported Diagnoses: Queries that suggest the inclusion of diagnoses not supported by clinical evidence or those that are not clearly linked to the patient’s condition may lead to denials. Payors may find such queries to be inappropriate or unsupported and may refuse payment.
6. Medical Necessity and Coverage Issues: Sometimes, queries may prompt documentation for conditions or services that may not be deemed medically necessary by the payer, resulting in a denial. Payors may challenge claims based on the perceived lack of documentation that supports the need for the care provided.
7. Inconsistent Documentation Practices: If a CDI query seeks to clarify a diagnosis or procedure, but the provider does not document the information in a way that aligns with coding guidelines, the query can lead to coding errors, which can then lead to a denial from payers.
8. Query Overload: If providers are overwhelmed with too many queries, especially on cases where the documentation is already clear, they may overlook or misinterpret some queries, leading to potential denials. This could also cause frustration, leading to less engagement or incomplete responses.
9. Lack of Appropriate Query Follow-Up: In some cases, CDI programs may not follow up on queries appropriately or may not provide enough clarification when providers have difficulty understanding the intent of the query. This can lead to confusion and, ultimately, denials.

Queries generate denials for a variety of reasons including payers utilizing specific clinical validation criteria that are not aligned with that of the payer, clinical validation criteria in constant flux by payers, the patient’s clinical story as documented by the physician not supporting the queried diagnosis, and conflicting clinical information in the chart that refutes the diagnosis queried. Other contributing factors include a post-discharge query, a query issued on the day of discharge, and a diagnosis dropped in the chart through a query that is not carried forward in subsequent progress notes and included in the discharge summary.

How to alleviate costly denials generated by the CDI profession through queries? Stop depending on queries as the mainstay of CDI activity. Queries do not change physician documentation practice patterns and do not serve as an effective means of providing documentation education to physicians. Queries are nothing more than a band-aid approach promoted by the CDI profession, ACDIS, and most consulting companies as the structural framework for the profession. Advances in AI will make the CDI profession obsolete in the next two or three years with most CDI professionals either ingrained in a lack of situational awareness or in complete denial, hoping they can continue to ride the same wave until it runs out of steam. The best course of action is to re-engineer, rebrand, repurpose, and reposition the role of CDI to facilitator of better documentation by working in collaboration with physicians, physician advisors, Case Management, Utilization Review, and Denial and Appeals to drive the achievement of optimal documentation that incorporates proactive preemptive denial avoidance documentation!

CDI Programs Generate Costly Denials!

?Why? Simply put, the CDI profession is preoccupied with scooping up CCs/MCCs through the fishing rod consisting of the query. Little emphasis and focus is on working with physicians to improve their documentation, documentation that serves as a communication tool for patient care, serving the needs of other physicians and other ancillary healthcare stakeholders. Narrowly defined task-based CDI activities with outcomes of reimbursement that lack sustainability and durability lack purpose and return on investment for CFOs

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Reach out to learn more about how Core-CDI tailors a physician-driven physician documentation program that focuses on the physician as the centerpiece leading to proactive preemptive denial avoidance and the transformation of denials management to denials avoidance