Clinical documentation improvement (CDI) are three buzz words in today's healthcare lingo that have come to signify a means of achieving better data quality that leads to more accurate reimbursement and perhaps even better patient care.
Most of the sources with whom I've spoken—including coders, nurses, and even physicians—advocate for the CDI efforts. However, one danger of such a program is that hospitals must ensure safeguards to prevent leading physicians down the long and winding path to a diagnosis.
Having a CDI program doesn't negate the fact that physicians must continue to maintain their authority in providing a diagnosis. And therein lays the conundrum for many hospitals: How to obtain this much-needed information without leading docs in the process.
Verbal queries, in particular, have remained a source of contention for hospitals simply because they are difficult to audit and monitor. Coders and CDI specialists know that they aren't supposed to lead physicians to a diagnosis, yet when questions are posed verbally, there is a significant risk that this will take place during course of conversation meant clarify documentation.
Hospitals need to specify—in their policies and procedures—why a coder or CDI specialist will initiate a verbal query as well as what the content of that verbal query will include. Consider adding the following language:
The clinical documentation specialist may have a discussion about a patient with a physician. This discussion will be an opportunity to educate the physician and to obtain specificity in the documentation. The clinical documentation specialist may discuss the clinical findings and documentation with the physicians involved in the care of the patient. The role of the clinical documentation specialist is to educate the physician on the specificity of verbiage which can result in improved capture of severity of illness. In addition, the clinical documentation specialist will pose verbal queries (questions) to the physicians so that clarification may be documented.
"I think having a policy in place that outlines the role of the CDI specialist and the parameters of the verbal queries will protect your organization if ever there is an outside review of your charts," says Melissa Ferron, RHIA, CCS, president, Melissa Ferron Healthcare Consulting, LLC.
In terms of creating a policy, hospitals should outline that the verbal query be designed to communicate the request or need for clarification based on existing clinical documentation. Consider adding the sentence "Under no circumstances will the CDI specialist tell the physician what to document," Ferron says.
Regardless of whether the verbal query is concurrent or post-discharge, hospitals should ensure that the individual posing the verbal query document the following information:
- Date of discussion with the physician
- Physician name
- Summary of the discussion
In terms of monitoring, verbal queries can pose a challenge. "By nature of a verbal query, there isn't a document that we can go to when comparing the composition of a verbal query from one coder or CDI specialist with another," Ferron says.
However, by encouraging documentation of verbal queries, health information management (HIM) directors or coding supervisors will have some data with which to work, Ferron adds. "If there is a high percentage of physicians adding diagnoses in the chart after the initiation of a verbal query, that might be a prompt that a verbal query is leading," she says. This could definitely raise a red flag for an outside reviewer.
Hospitals may also want to consider a direct observation technique in which an HIM director or coding supervisor observes those who are posing verbal queries. "It might be a little more labor intensive, but I think that nonetheless, you need to have that in your policy," she adds.