HIM Coding Professionals Told They’re Not Qualified to Query for Clinical Validity

Trends in Clinical Documentation, Past, Present, and Future – Part I

For nearly a century, since Grace W. Myers of Massachusetts General Hospital became the first medical records librarian in the early 1900s and the American College of Surgeons (ACOS) sought to improve the standards of medical records being created in clinical settings in 1928, documentation trends have continued to make news. Today, thanks to the implementation of electronic health record (EHRs) and the rise of the health information management (HIM) industry, they’re making more news than ever.

Medical record documentation started out in the simplest of forms. It was created by writing down on paper a patient’s symptoms and treatment by a single doctor. It has evolved into a comprehensive, computerized system of data collection used by many within a totally integrated health record and shared by many throughout a large health system at the same time.  

Is clinical documentation headed in the right direction? Are there bumps in the road that demand our quick attention? If so, are we going to ignore them and fall prey to the words made famous by George Santayana (philosopher, poet, and humanist) when he said, “those who do not remember the past are condemned to repeat it?” Let’s take a look into the past, present, and future and see.

Clinical documentation improvement (CDI) programs began as a revenue optimization strategy promoted by healthcare consulting companies in the early 1980s, after the advent of diagnosis-related groups (DRGs). The buzzword at that time was “DRG optimization,” which became popular in many hospital facilities that hired consulting firms that promoted these practices and techniques. This eventually caught the attention of the Centers for Medicare & Medicaid Services (CMS), then known as the Health Care Financing Administration (HCFA), resulting in increased scrutiny because of what was seen as possibly “gaming” the system, or up-coding to maximize reimbursement.

In 1998, as part of the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan, the “Pneumonia Coding Project” was announced.

In the OIG’s words:

  • “The Pneumonia DRG Up-coding Project was initiated to identify hospitals that falsify the diagnosis and diagnosis-related group (DRG) on claims from viral to bacterial pneumonia. The Office of Investigations is currently working with the Department of Justice to initiate a nationwide project in this area.”

In 1999, the OIG in its Work Plan revised its description to note that the government would investigate pneumonia cases as both civil and criminal matters.

DRG optimization caught the attention of hospital CFOs due to huge paybacks required for “over-coding.” In the late 1990s and early 2000s, the importance of CDI initiatives continued to evolve with more sophisticated tracking systems, automated query processes, and employment of certified CDI specialists who continue to grow more sophisticated in their methods. These CDI initiatives began in medical records, with coding professionals who were trained in reading and interpreting clinical documentation querying physicians when the documentation was inconsistent, unclear, vague, or lacking clinical validity or other information related to specificity and accuracy.

Looking at the present, many CDI initiatives are missing a key element that is fundamental to successfully making the transition to value-based, cost-effective, and quality-driven alternate payment healthcare delivery models – namely, real and recognizable clinical documentation improvement. There are some CDI programs that are still just going after complications and comorbidities (CCs) and major CCs (MCCs) for the purpose of optimizing reimbursement and not focusing on improving overall clinical documentation itself. These programs also tend to focus mostly on conditions that yield higher reimbursement, or avoiding a patient safety indicator (PSI) or hospital-acquired condition (HAC). Although it might be tempting for both CDI and coders to want to define diagnoses for a provider, it is not within the scope of either a CDI, registered nurse, or coding professional to do so. Overly aggressive CDI practices can put a hospital at high risk, as it did in times past.    

The past still haunts me, as many highly respected and recognized consulting companies and physicians are seemingly agreeing with this notion and telling hospital CFO/CEOs that HIM coding professionals are not qualified to perform the role of a CDI specialist, and that only nurses and doctors are qualified. Many articles are being written regurgitating the Statement of Work (SOW) promulgated by the Recovery Audit Contractors (RACs) defining the difference between a DRG validation versus clinical validation as being a separate process that involves a clinical review of the case to see whether the patient truly possessed the conditions that were documented. The statement was made that clinical validation is beyond the scope of DRG (coding) validation, or the skills of a certified coder. 

Many used this statement to support their position that CMS is saying coding professionals aren’t qualified to be a clinical documentation improvement specialist (CDIS), which is not the case at all.  Per the SOW, the RACs are required to employ certified coders, registered nurses, therapists, and a dedicated MD medical director to oversee the team. They are encouraged to use a panel of clinical experts. The intent of this SOW was solely to describe standards to which CMS holds the RACs; it does not exclude HIM coding professionals from the clinical validation process before the claim is dropped or as part of the denial management team.

The SOW that applies to the current RACs is available online here: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Resources.html.

Many CDI firms have seized upon such statements to say they mean that validation may not be performed by a coding professional at a hospital facility. It is true that the function of coding is different than the function of CDI, but the ideal end result is both coming to the same conclusion with the same DRG or severity of illness and risk of mortality (SOI/ROM), based on the physician’s documentation and accepted clinical criteria. Fundamentally, a coding professional is compelled to code what is documented following the Official Coding and Reporting Guidelines and Uniform Hospital Discharge Data Set (UHDDS) rules. Coding has a different technical approach from CDI, but that doesn’t mean a professional coder can’t function as a CDIS, issuing clinical validation queries.  

To say that seasoned coding professionals are not clinically competent or trained well enough to interpret clinical terms and concepts from the medical record is absurd! They have been doing it for decades. HIM coding professionals come from all different backgrounds, experiences, and skill sets. You can’t roll all of them into one category because they include beginners, intermediates, and advanced coding professionals, e.g. those who are credentialed by AAPC and/or AHIMA with a RHIA, RHIT, CCS, CPC, or CDIP, or credentialed by ACDIS with a CCDS. Those of us who consider ourselves advanced and seasoned coders have taken the same clinical courses that nurses take, a list that includes medical terminology, A&P, pathophysiology and pharmacology, plus all the coding courses and requirements of the American Hospital Association (AHA) Coding Clinics. We have read thousands upon thousands of pages of clinical medical record content. To say all coding professionals cannot interpret clinical concepts is a misrepresentation of the truth. Are all coding professionals qualified or capable? The answer would be no. Are all nurses qualified and capable?  The answer is again no; the RN also must be trained to learn all the coding guidelines and concepts. It takes a person who is highly competent, well–trained, and advanced in their knowledge of clinical concepts and medicine, who also understands coding guidelines and principles as well. It also takes a certain kind of personality, with the soft skills to communicate well, both written and verbally, and interact well with physicians and other hospital executives and departments.

I believe that the best model is one in which different coders can benefit from each other’s strengths and weaknesses and learn from each other to ensure overall completeness, consistency, organization, and accuracy of the medical record, reflecting the physician’s clinical judgment and medical decision-making. With that being the primary purpose, keep in mind that by improving the overall clinical documentation in the medical record, reimbursement will be a byproduct. 

Advocating for the best practices of ensuring consistent, clear, and compliant documentation reflective of medical necessity for inpatient care, continued hospitalization stay, appropriate resource consumption, and utilization review, with the achieved outcomes of accurate clinical validation of all assigned ICD-10-CM/PCS codes and DRG assignment that can be defended and clinically supported in an audit, is the best proactive approach to any good CDI program. Clinical validation means that diagnoses documented in a patient’s record and coded for claims submission must be substantiated by generally accepted clinical criteria. Almost all payors perform selected reviews of clinicians’ claims for clinical validation, and unfavorable findings may result in denied claims, reduced payment, or more serious consequences.  

Over the last five years, a disturbing trend has been emerging all over the country. It involves a distortion that is being propagated over and over again, and no one is stopping it; therefore, it is now believed to be the truth by many. To discover the motivation for it, you only need to “follow the money,” as the saying goes. 

Consulting companies that are hiring and contracting out CDISs are now saying that only a RN, MD, or DO qualifies to do the job of a CDIS. Why would that all of a sudden be the new truth? Because the contractors can charge much more money for a nurse or doctor than an experienced coding professional: voila. Also, hospital CFO/CEOs are being convinced by these consulting companies that they will ensure consistent increases in monthly case mix, achieved through these CDI initiatives. 

The notion that “those who do not remember the past are condemned to repeat it” needs to be restated. Don’t forget the past, as in that these consulting companies were telling hospital CFO/CEOs in the 1980s and 1990s that they can help optimize their hospitals’ reimbursement – much in the same way they today are convincing people that only nurses and doctors are qualified to write queries, educate providers, and perform the required responsibilities of a CDIS who will improve documentation and case mix index (CMI) and bottom-line revenue. Overly aggressive CDI can come with great risk to any organization. 

Now and in the future, those of us who are clinically competent, experienced, and trained to be a CDIS are and will be losing their jobs and/or not advancing in their careers. HIM coding professionals are being discouraged or told not to query physicians anymore because “the CDI RNs are the only ones qualified to do it.” Even though Medlearn Compliance, this message is being repeated; in its July 2011 edition, the publication told coders that they should query for acute respiratory failure versus hypoxemia when the clinical evidence is not supported in the medical record. Likewise, in AHIMA’s Practice Brief on writing a compliant query, a diagnosis is listed without the underlying clinical criteria. 

HIM coding professionals are being told they are not clinical enough, and that clinical validation is beyond the scope of their jobs, while we have two authorities citing when a coder should query for clinical validity. 

HIM coding professionals that would like to advance their careers in CDI are being locked out because no one is doing anything to stop this. It is even being allowed by our own HIM association (AHIMA), which inadvertently is allowing this message to be propagated without taking a strong, hard stand against it, even within the organization. They allow job postings for profit that only recognize RNs as qualified. They allow presenters to advocate for RNs only. They allow articles to be written that imply only CDI RNs are best suited for the role of a CDI specialist. AHIMA’s own employees will not acknowledge this is happening, even though they continue to market the CDIP credential when there are few jobs for HIM coding professionals that allow them to become a CDIS.

It is felt by many that AHIMA needs to advocate for change now and take that hard and strong stance against what is happening in the clinical documentation industry. AHIMA’s seeming endorsement that RNs/MDs/DOs are best suited in the role of a CDIS is particularly harmful for our coding professionals, now and in the future. We are hoping that AHIMA will provide clarification in its upcoming article, Clinical Validation: The next level of CDI (2016), and write a position paper on this debate.  

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