First Things First...

The medical record serves as a communication tool first and foremost with reimbursement as a byproduct of complete and accurate physician documentation. Clinical documentation integrity programs exist to improve the quality and completeness of the physician's documentation that supports a myriad of roles including quality outcomes, safety measures, risk adjustment, severity of illness/risk of mortality measures, medicolegal risk, and reimbursement to name just a few. There is inarguably too much emphasis today in most CDI programs upon task based activities that are intended to generate increased reimbursement through CC/MCC capture and/or principal diagnosis clarification. While these elements are an essential part of any clinical documentation integrity program, the reality is that the CDI profession is overlooking a critical part of the role comprising actual improvement in physician documentation beginning with the Emergency Department and the History and Physical. The documentation in the ED and the History and Physical serve to patient the patient's clinical story, what is wrong with the patient, how did it manifest, and what is going on with the patient. Before attempting to identify additional diagnoses or diagnoses requiring clarification through the query process, the CDI professional should be evaluating the medical record for establishment of medical necessity. The physician hospitalizing the patient maintains responsibility for establishing medical necessity through his/her documentation.

Medical Necessity-It's A Physician Thing

Payers utilize screening criteria (Milliman Care Guidelines, Interqual) in determining whether a patient hospitalization should be assigned an inpatient level of care. Screening criteria is just that, screening criteria, with the medical record documentation painting the picture of patient clinical acuity, clinical severity, and patient story. The patient story begins with the patient's Chief Complaint and History of Present Illness. A History of Present Illness is defined as a chronological description of the development of the patient’s present illness from the first sign and/ or symptom or from the previous encounter to the present. There are eight elements of HPI as follows:

1. Location (example: left leg)
2. Quality (example: aching, burning, radiating pain)
3. Severity (example: 10 on a scale of 1 to 10)
4. Duration (example: started 3 days ago)
5. Timing (example: constant or comes and goes)
6. Context (example: lifted large object at work)
7. Modifying factors (example: better when heat is applied)
8. Associated signs

The History of Present Illness (HPI) is where the CDI specialists should begin the chart review process with identification of at least four elements documented. A well described and told patient story that shows, paints, reflects, and depicts the patient's clinical acuity and severity is the prism through which medical necessity is seen by an outside reader like CDI. When I review a record from a CDI perspective, I ask myself what does the HPI as recorded by the physician tell me. Does it catch my attention like an introduction in a novel or does it appear to be "boring," a tell tale sign that the novel is not going to be enjoyable and intriguing to read. If the CDI specialists does not clearly see the patient's severity of signs and symptoms and other details that show a sick patient requiring hospital level of care, there potentially is room for improvement, working with the physician to best accurately describe and tell the patient story. There should be a minimum of four elements of the HPI to adequately describe and tell the patient story; without at least four elements it is hard to gauge the need for hospital level of care, whether observation or inpatient.

The following represents a sufficient HPI that adequately tells, describes, and reflects a patient's clinical story, demonstrating and reflecting a high patient clinical acuity that in conjunction with the Physical Exam findings and observation, diagnostic results and findings, Assessment, and Plan, may represent a patient who requires inpatient level of care. A well crafted and reported HPI serves to support the physician's assessment with definitive and provisional diagnoses traceable back to the severity of signs and symptoms documented in the HPI.

• 58 y.o. male with hypoxia and fever that developed earlier today. The patient is a resident of a facility that cares for patients with chronic intellectual and physical disability. Apparently, per his nursing staff he has had progressively worsening functional decline over the last several months to years. This has rendered him on a long-term basis as bed-bound and nonverbal with blindness. Today, by report, the patient was noted to have oxygen saturations of 85% and an elevated temperature of a 100.2°. He apparently undergoes bolus tube feeds via a PEG tube and it had recently been replaced at an outside facility. He was evaluated at a emergency department an outside hospital but due to the complexity of his case he has been transferred to the intensive care unit at for further management. On initial exam the patient is nonverbal and unable to provide any elements of the history and physical. Per report at outside emergency department, stomach was decompressed with Foley catheter bag and a large amount of yellowish thick liquid came out. Patient weaned off BiPAP. He responds to physical stimuli but is nonverbal and does not participate in exam. The patient had improved substantially and was weaned off of oxygen. He was preparing to be discharged back to his facility. Unfortunately he became hypoxic again with low-grade fever and repeat imaging revealed new left lower lobe consolidation. He is now being treated for a acute bacterial pneumonia

Let's review the Assessment where based in part upon the HPI and other elements in the chart the diagnoses chart are reasonable with inclusion of clinical rationale and thought processes:

• This is a _58 y.o._ _male_ with sepsis and acute respiratory failure with hypoxia secondary to pneumonia

• Sepsis Clinical indicators at time of admission include the following: White blood cell count 18.5, temperature 100.9° F, respiratory rate 30 breaths per minute or greater, heart rate greater than 100 beats per minute, evidence of end-organ damage with lactic acid elevation at 4.6, infectious etiology of pneumonia as well as urinary tract infection. Patient did become hypotensive briefly at 1 point at time of admission but did respond to IV fluids. He was admitted to the intensive care unit due to the lability of his hemodynamic status.
• Acute respiratory failure with hypoxia Clinical indicators at time of admission include the following: Reports of possible aspiration event with vomiting likely causing a pneumonia, CT scan of chest demonstrated bibasilar opacities consistent with pneumonia, oxygen saturations of 85% on room air documented, respiratory rates of greater than 30 breaths per minute documented. Continue supplemental oxygen, he has been weaned off BiPAP. Pulmonology/critical Care consult obtained Patient now has a recurrence of hypoxia likely due to another healthcare acquired bacterial pneumonia and/or aspiration event. He likely needs ongoing chest PT and has been restarted on an antibiotic course of therapy as well. White blood cell count continues to increase as does oxygen requirement Check COVID swab
• Pneumonia, presumed aspiration Per report, the patient did have a vomiting episode at the time of admission. This likely led to aspiration with his current sepsis and respiratory distress. Vomiting may have been induced by patient's severe fecal impaction and he was a placed on aggressive bowel regimen. It appears he now has a left lower lobe pneumonia which may have been a result of another aspiration event or could be an bacterial healthcare acquired pneumonia. He is empirically started on broad-spectrum antibiotics to complete an additional 7 day course of therapy.
• Urinary tract infection This appears to be present on admission based on urinalysis. Continue current medications used to treat underlying pneumonia as they should cover for any potential UTI. No urine culture was performed apparently
• Functional quadriplegia The patient has contractures in all 4 extremities and is a functional quadriplegic. In addition, he is blind and unable to communicate either verbally or nonverbally. These conditions are all irreversible with no available treatment. As such, should he have any cardiac or pulmonary failure resulting in cessation of cardiopulmonary function, it is felt that it would be inhumane to attempt cardiopulmonary resuscitation. Accordingly it is my recommendation that this patient be made a do not resuscitate

Putting the Horse Before the Cart

Generating queries for financial impact without addressing documentation insufficiencies in the Emergency Department and the History and Physical will only serve to generate more payer clinical validation denials and DRG downgrades. Every hospital is currently facing increasing volume of denials and while some of these are attributable to egregious behavior on the part of the payer, a large portion are attributable to insufficient physician documentation in support of diagnoses within the assessment. As a result, the payers are having a field day hitting it out of the park with denials. I submit to all CDI professionals the need to broaden the depth and extent of chart reviews, working with physicians, physician advisors, case managers and utilization review staff, to assist in the capture the essence of the patient clinical story right beginning with the ED and H & P documentation. A clear and accurate clinical picture of the patient story is essential to laying the groundwork for establishment of medical necessity and clinical validation of diagnoses associated with explaining the need for hospital level of care. This approach to CDI will drive better operational performance and generate better financial return on investment for the hospital, something desperately needed with all the financial challenges hospitals current face and will continue to face.