Potential Dangers to Physicians of Answering CDI Queries

Physicians answering Clinical Documentation Improvement (CDI) queries can present several potential dangers or risks, both from a clinical and legal perspective. While it is important to ensure documentation is accurate and complete, the involvement of physicians in answering CDI queries directly can introduce significant complications. Here are some key concerns:

1. Potential for Undocumented or Inaccurate Information

• Incomplete or Ambiguous Responses: Physicians may provide responses that are too brief or not sufficiently detailed, leading to incomplete or inaccurate documentation that can affect the patient’s medical record. Often, queries are issued towards the end of the patient’s stay or after the patient has been discharged where the patient’s clinical condition at the time the query is issued no longer signifies and supports the diagnosis. The payer will undoubtedly deny commonly queried diagnoses at this point based on clinical validation; they contend that if the diagnosis was so relevant to the initial hospitalization, then why is the diagnosis appearing after the stay? Word of caution to physicians, be judicious and careful of answering retrospective queries, particularly, those queries issued after discharge.
• Over-Simplification: Physicians might simplify their answers in ways that could result in the documentation not reflecting the complexity of the patient’s condition or treatment accurately. Queries are designed and intended to capture diagnosis for reimbursement purposes when the patient’s clinical story may not depict and reflect the clinical picture of the diagnosis queried for by CDI. Many a sepsis or acute hypoxemic respiratory failure query may contain the clinical indicators to support the diagnosis, yet the clinical picture as described and told in the record fails to support the diagnosis. The result is a self-inflicted costly clinical validation denial that cannot be successfully overturned by the hospital.

2. Risk of Upcoding or Downcoding

• Upcoding: Physicians may inadvertently be pushed to answer queries in ways that lead to over-documentation or upcoding—assigning a higher severity diagnosis or procedure than is supported by the clinical evidence. This can lead to financial penalties or audits from payers. Physicians are aware that they must answer queries as part of their practice of medicine and know what the CDIS is charged with accomplishing. In the quest to clear out their email boxes filled with queries, there is always the tendency of physicians to quickly clear out the queries by checking off the first answer to the query which often is the desired physician response.
• Downcoding: On the flip side, not fully capturing the extent of a patient’s condition (under-documentation) may lead to under-reimbursement for the level of care provided.

3. Legal and Compliance Risks

• Fraud and Abuse Concerns: If physicians are perceived to be answering queries in a way that manipulates coding for financial gain, there could be concerns about compliance with federal regulations (e.g., the False Claims Act). This could lead to investigations, fines, or even legal action.
• Defensibility of Documentation: If a physician's responses to CDI queries are not clear or medically justified, it could become difficult to defend the medical record in a legal context, such as during malpractice litigation. The author of this blog has collaborated with a defendant's attorney on a malpractice case where the plaintiff's attorney was questioning the purpose and validity of two queries within the record. The queries were for cerebral edema post-surgery and acute blood loss anemia, both issued by the same CDIS at the same time. The attending physician was questioned on the stand as to the clinical significance of these diagnoses considering the fact the record lacked any documentation of the clinical significance of these diagnoses and what his clinical thoughts and rationale for action or lack thereof.
• Physicians must recognize that the inpatient record is used for coding and billing of the hospital facility MS-DRG/APR-DRG as well as the professional charges for their services rendered to the patient. The HCFA 1500 claim form contains a field for the physician's electronic signature on the front and on the back is an attestation statement as follows:

?4. Confusion Between Clinical and Coding Roles

• Separation of Duties: The role of a CDI specialist is primarily focused on improving documentation for coding accuracy and reimbursement, while the physician's primary responsibility is patient care and clinical decision-making. If physicians engage too much in the CDI process, it could blur the lines between these roles, potentially leading to conflicts of interest or ethical concerns.
• Physician Burden: Physicians are already overwhelmed with clinical responsibilities and do not always have the time or expertise to answer CDI queries thoroughly. This can lead to rushed responses that do not fully reflect the patient's condition or are not aligned with coding standards. Physicians are faced with ongoing competing forces with documentation tending to take a back seat given all the responsibilities and duties assigned to them, not considering the tremendous ongoing time-consuming challenges of navigating, charting, and clicking away in the health record. Ongoing repetitive reactionary transactional queries just add to the complexities and time constraints imposed upon physicians.

5. Impact on Physician-Patient Relationship

• Time Constraints: Physicians may feel pressure to spend more time answering queries than focusing on patient care, which could impact their ability to provide timely and effective medical services.
• Documentation Fatigue: Repetitive or excessive CDI queries could contribute to burnout or frustration for physicians, affecting the overall quality of care and job satisfaction.

6. Potential for Documentation Errors

• Lack of Familiarity with Coding Conventions: Physicians may not be well-versed in coding guidelines, such as ICD-10 codes or the nuances of Hierarchical Condition Category (HCC) coding. As a result, their responses might not align with proper coding protocols, leading to incorrect or inconsistent documentation.
• Miscommunication: CDI queries may not always be clearly understood by the physician, especially if the query is not worded in a way that aligns with clinical terminology or if the physician is unfamiliar with the terminology used by CDI specialists. This can lead to inaccurate or unclear documentation.

7. Pressure to Document for Financial Purposes

• Financial Incentives: While CDI initiatives are designed to ensure accurate and complete documentation, there may be concerns about physicians being encouraged or pressured to document in ways that primarily serve financial goals, rather than solely focusing on patient care and clinical accuracy. Some programs issue report cards to physicians on their monthly CC/MCC Capture Rate, CMI, and RVU generation which only serves to perpetuate the financial stick physicians are experiencing in numerous facilities.

Best Practices to Mitigate Risks:

To avoid these dangers, healthcare organizations must implement best practices such as:

• Collaborative Query Process: Having CDI specialists and physicians work together with clear roles and responsibilities, ensuring that clinical documentation is accurate without overstepping into coding or financial concerns.
• Training and Education: Providing physicians with training on how to properly respond to CDI queries while ensuring clinical integrity and documentation compliance. Simply checking off a box on a query without considering the clinical story, clinical information, and clinical context as documented within the chart is a recipe for physicians’ exposing themselves to compliance risk and potential fraud and abuse allegations
• Clear Documentation Guidelines: Establishing clear guidelines for CDI specialists on how to phrase queries, ensuring they are clinically accurate, understandable, and respectful of the physician's expertise.
• Use of Technology: Leveraging technology to streamline the query process, reducing physician burden and ensuring that responses are automatically aligned with coding standards.

By maintaining a clear division of responsibilities, fostering communication between CDI specialists and physicians, and ensuring compliance with documentation standards, many of these risks can be minimized. Caution is encouraged by physicians in answering any query, particularly automated queries, to ensure that the query is clinically relevant and the response to the query is fully supported by the documentation in the record. Physicians must remember that their NPI number and electronic signature are on the claim signifying an attestation that the diagnoses are supported by the clinical facts and clinical information provided in the medical by the physician.

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