Stay the Course
On August 2nd, a collective sigh of relief was heard across the country with the release of the Inpatient Prospective Payment System (IPPS) FY 2020 Final Rule, which revealed that the severity designations described in the IPPS FY 2020 Proposed Rule would not be applied. The strength of the Clinical Document Integrity (CDI) and Health Information Management (HIM) communities during the comment period was evident as they stood together in support of the patient.
As rewarding as it was to see the solidarity in support of the complexity of care of the patient and how that is reflected in the severity designations, the one thing we’ve been able to count on is change – it has always been this way and will always be this way. That being said, and knowing that it is likely that at least some of those changes (and likely more) will be adopted in the future, there is one constant in the midst of all this change – the patient. As we move forward, we need to stay the course and continue to focus on the patient.
The clinical care team, those whose attention is the care of the patient, is laser focused on the patient and that is where the CDI professional, who is a member of the clinical medical record team should remain focused.
This article does not purport disregarding the guidelines and rules that govern code assignment, but looking at this logically with the end in mind, in order for what can be called the “coding medical record team” to have any codes to assign, there must be documentation. In order to have documentation, there must be a patient. With a mission to support credible documentation of the patient’s health status, the CDI professional plays an integral role as a member of what can be called the “clinical medical record team”. If the CDI professional does not focus first on the patient, we are doing a disservice not only to the patient, but to the provider, the direct caregiver, the payer, and the coding professional.
The primary goal of the CDI professional is to ensure the medical record completely and precisely depicts the patient’s health status. As the CDI professional focuses on the documentation surrounding the patient’s conditions and diagnoses according to the guidelines governing that setting, they assist the provider to document to the diagnostic specificity the clinical picture describes in the medical record, which in turn creates a defensible final coded record.
In order to focus on the documented patient’s conditions and diagnoses, clinical validation is the key. By having knowledge of the clinical indicators and the expertise to identify a possible condition and/or the specificity of the condition portrayed by the clinical evidence in the medical record, clinical validation from the provider can be attained. Clinical validation is the basis for focusing on the patient and can be defined as the confirmation of the point where a certain clinical threshold is met by a documented diagnosis (AHIMA, 2019). Focusing on support for the diagnosis instead of placing the focus on the code(s) for the diagnosis is the key. This means emphasis is first on the clinical aspect, with the coding aspect focus subsequently placed on the clinically validated documentation.
Whether the CDI professional is reviewing the record for clinical evidence that appears to support a diagnosis and/or specificity, or identifying an apparent lack of clinical evidence for a documented condition/diagnosis, the key is the patient and the exhibited clinical evidence.
By staying the course and focusing on the patient, we can uphold the integrity of the medical record, regardless of the changes to any classification system (MS-DRG, APR-DRG, CMS-HCC, HHS-HCC, CPT, HCPCS, etc.), thereby stabilizing code assignment and the medical record to withstand any audit and will serve to only speak the truth as it pertains to the patient’s health status.
Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP, CCDS-O
MRC CDI Content Manager
Reference: AHIMA. 2019. Clinical Validation: The Next Level of CDI (January 2019 Update).