Role of CDI in Avoiding Costly Payer Denials

Avoiding medical necessity denials requires a proactive preemptive approach to documentation and adherence to physician documentation guidelines. Clinical Documentation Integrity Specialists play a pivotal role in collaborating with physicians, case managers, utilization review, physician advisors, physicians, and denials and appeals to drive the achievement of better documentation. Better documentation refers to measurable meaningful sustainable improvement documentation that focuses on proactive preemptive denial avoidance. Here are several strategies that CDI professionals in conjunction with healthcare providers and facilities can implement:

1.????? Educate and Train Staff: Ensure that healthcare providers and documentation specialists receive ongoing education and training on medical necessity criteria, coding guidelines, and documentation requirements. This helps them understand what constitutes medical necessity and how to document it effectively.

2.????? Use Evidence-Based Guidelines: Refer to evidence-based clinical guidelines and criteria when determining the medical necessity of services and procedures. Document how the patient's condition meets these criteria in the medical record. An adequate concise History of the Present Illness in conjunction with a physical exam correlating with the nature of the presenting problem and clinical judgment of the physician; an Assessment that can be traced back to the patient’s presenting signs and symptoms, physical exam, abnormal radiology, laboratory and other diagnostic workup results, response to treatment in the ED; and plan of care that is reasonable, rationale, and directly correlates with the assessment constitutes the standards of documentation for all providers.

3.????? Document Comprehensively: Ensure that all aspects of the patient's condition, including history, physical examination findings, diagnostic tests, and treatment rationale, are clearly documented. Avoid vague or incomplete documentation that may lead to misunderstandings, the creation of opportunities for payers to refute the diagnosis or the need for an inpatient level of care and second-guessing of the physician's clinical judgment and medical decision-making by the payer's medical director.

4.????? Link Diagnoses to Treatments: Establish a link between the patient's diagnosis and the treatments or services provided. Document how the treatment plan is specifically tailored to address the patient's condition and medical needs. Unequivocally show and demonstrate how the physician’s work performed met the patient’s clinical needs and could only be addressed and effectively managed in the hospital setting.

5.????? Document Severity of Illness: Describe the severity of the patient's condition and any complicating medical factors including relevant history and active comorbidities, severity of signs and symptoms, and the need for hospital level of service based upon the patient’s current medical needs that justify the need for the services provided. Include details on the patient's functional status and how it impacts their treatment requirements.

6.????? Avoid Over-documentation: While comprehensive documentation is crucial, avoid unnecessary or excessive documentation that could potentially confuse or contradict the medical necessity of the services provided. The provider must meet the standards of documentation that promote concise, organized, consistent, contemporaneous, and relevant documentation, capturing the essence of the patient story with a strong introduction, body, and conclusion reading like a short action-packed factual novel.

7.????? Utilize Templates and Checklists: Implement documentation templates, dot phrases, or checklists that guide providers through the necessary elements for documenting medical necessity. This helps ensure consistency and completeness in documentation practices.

8.????? Review and Audit Documentation: Conduct regular audits of documentation practices to identify areas for improvement and ensure compliance with medical necessity requirements. Provide feedback and additional training as needed based on audit findings. Provide feedback on payer medical necessity and clinical validation denials to physicians, meeting with physicians to improve their documentation, addressing documentation shortfalls and inconsistencies that contributed to the adverse determination by the payer.

9.????? Communicate Effectively: Foster open communication among healthcare team members to ensure a shared understanding of the patient's clinical status and treatment plan. Clear communication helps in documenting medical necessity accurately. Physician documentation integrity requires a “team-based approach” as opposed to the current siloed approach to CDI that contributes to the tunneled vision and lack of situational awareness on the part of the CDI profession.

10.? Stay Updated on Regulations: Keep abreast of changes in regulatory requirements, payer policies, and guidelines related to medical necessity. Ensure that documentation practices align with these updates to minimize denials. The CDI profession must serve as a conduit to best practice standards and principles of documentation for physicians, sharing payer updates and constantly changing documentation requirements for specific services and general adherence to medical necessity requirements.

By implementing these strategies, the CDI profession can assist healthcare providers and facilities reduce the risk of medical necessity denials, ensuring that reimbursement is appropriate and timely for the services provided to patients. The CDI profession plays a vital role in driving the achievement of physician clinical documentation excellence, using a balanced team-based approach that engages all physicians and ancillary stakeholders on behalf of the patient and supports an optimal high-performing revenue cycle. ?