Can I Code Arthroscopic Plica Removal and Arthroscopic Meniscectomy in the Same Episode?

I was recently asked about the appropriateness of coding both CPT codes 29875 (arthroscopic plica removal) and 29881 (arthroscopic meniscectomy) for the same episode of care.  This “In the kNOW” installment will provide the answer and examine the rationale behind it.
 
CPT code 29875 is assigned for a limited synovectomy.  This procedure is often referred to as a plica resection or shelf resection, and within CPT, it carries a designation of being a “separate procedure”.  This “separate procedure” designation is often where the confusion lies.  In general, when a procedure is designated as a “separate procedure” it means it is considered to be fundamental component of a larger or more total procedure and is therefore, not to be coded additionally.  However, as every coder knows, there are exceptions to every guideline provided, and the “separate procedure” is not exempt because, in circumstances where the “separate procedure” is clearly distinct from other procedures, it may be reported with modifier 59.  In order for the exception to apply, the “separate procedure” must meet one of the following conditions:

• It represents a different session
• It was a different procedure/surgery
• It represents a different site or body system
• It required a separate surgical approach
• It was a different lesion
• It was a separate injury

Armed with this information, let’s now look at the coding question posed above.  Our main procedure will be the arthroscopic meniscectomy as it is the more extensive procedure performed.  In order to code the plica resection, it would have to meet one of the exceptions listed above, which normally it does not.  These plicectomy procedures are usually performed through the scope insertion, at the same time as the more extensive procedure, and don’t represent a different lesion/injury.  So this becomes the first clue that we shouldn’t code both of these procedures at the same time. 

If we dig even deeper and find a copy of the procedure-to-procedure edits from the Centers for Medicare and Medicaid Services (CMS), we can identify that 29881 is the column 1 procedure with 29875 the column 2 procedure and an edit rationale that states 29881 is considered to be the more extensive procedure.  We do find that we could bypass the edit with the use of an appropriate modifier, but again, keep in mind, that we would need to meet one of the exceptions that we mentioned above, which we don’t.  However, if the plica resection was done in the left knee and the meniscectomy was done in the right knee, a modifier would be appropriate to indicate that both procedures should be paid in this instance since they meet the exception of different body site. 

Further investigation takes us to the National Correct Coding Initiative (NCCI) edit manual.  In Chapter 4 which addresses the musculoskeletal codes in the range of 20000-29999, we go to Section E-Arthroscopy, and then to #8.  Here we are told that 29875 is not to be coded when any other procedure is also performed via arthroscopy in the same knee.

Our final confirmation is addressed in the CPT Assistant from January 2016 on page 11.  That document reiterates the information related to “separate procedures” and states that 29875 is not to be coded with 29881.

It is clear from four different sources that coding of both 29875 and 29881 is not normally going to be reportable.  Should a coder have a situation where one of the exceptions mentioned applies, use of an appropriate modifier will bypass the edit and trigger reimbursement.

 Now you are in the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

Texting of Patient Information Among Healthcare Providers - Memo from CMS

• Texting patient information among members of the health care team is permissible if accomplished through a secure platform.
• Texting of patient orders is prohibited regardless of the platform utilized.
• Computerized Provider Order Entry (CPOE) is the preferred method of order entry by a provider.

 
CMS recognizes that the use of texting as a means of communication with other members of the healthcare team has become an essential and valuable means of communication among the team
members. In order to be compliant with the CoPs or CfCs, all providers must utilize and maintain systems/platforms that are secure, encrypted, and minimize the risks to patient privacy and
confidentiality as per HIPAA regulations and the CoPs or CfCs. It is expected that providers/organizations will implement procedures/processes that routinely assess the security
and integrity of the texting systems/platforms that are being utilized, in order to avoid negative outcomes that could compromise the care of patients.

Read the full memo here: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-18-10.pdf

Statewide Standard Authorization Form - We Need Your Input!

In 2012, Governor Kasich proposed and the Ohio General Assembly enacted legislation to harmonize state privacy law with federal law (RC 3798.02). Prior to the change, state law applied standards for information sharing that in some cases were inconsistent with federal privacy law, which created barriers to electronic health information exchange and care coordination.

The new law also required Ohio Medicaid to develop a standard authorization form for the use and disclosure of protected health information (RC 3798.10).  The purpose of the standard form is to improve care coordination for a patient across multiple providers by making it easier to share protected health information in a secure manner. The form is not required to be used, but a properly executed form must be accepted by the entity receiving it.

Ohio Medicaid developed the standard authorization form (draft below) as part of the broader statewide initiative to integrate physical and behavioral health care services within Medicaid managed care. The form was developed as a partnership among state agencies, behavioral health providers, hospitals, health plans, health information exchanges, and criminal justice, including the Attorney General’s Task Force on Criminal Justice and Mental Illness.

The form is currently being field-tested at several hospitals.  The next step is for Ohio Medicaid to submit a draft rule, including the form and instructions how to use it, to the Common Sense Initiative for review.  At the same time, outreach will occur to a broader group of stakeholders (OHIMA included) for input on the form itself and to test and refine technical assistance documents that support using the form in a broad variety of circumstances and settings. The goal is to have the standard authorization form and rule adopted and in use before the end of the year.

• FORM (draft) - EXPIRED
  
• INSTRUCTIONS (draft) - EXPIRED

Please review the draft form and instructions.  If you have any comments (positive or negative), fill out this SURVEY (EXPIRED) by Monday, June 18th.  Your comments will be reviewed by an OHIMA taskforce who will formally submit our comments to Ohio Medicaid.  If you are interested in serving on OHIMA's taskforce, please indicate your interest within the survey above.  

Staunching The Tide of Medical Necessity Denials

by Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-CDAM

The Importance of CDI Involvement in Denials and Appeals

Denials and appeal is a major challenge for hospitals with the Advisory Board’s biennial revenue cycle survey finding that a median 350-bed hospital would have lost $3.5 million to increased denial write-offs from healthcare payers over the past four years. Hospitals wrote off as uncollectable 90% more denials than six years ago, a difference of $3.5 million for a median 350-bed hospital, according to the report. The Advisory Board found that the median for successful denial appeals for hospitals fell from 56% to 45% for commercial payers over the past two years and from 51% to 41% for Medicaid. (Fierce Healthcare Article- November 15, 2017 Denials Rampant. Medical necessity denials continue to grow exponentially as third-party payers become more aggressive in denying care both in the inpatient and outpatient setting as part of a major business strategy to reduce the medical loss ratio, the amount insurance companies pay out for actual care provided compared to the premiums they collect, in the interest of increasing profits and shareholder and C suite annual payouts.

Hospital’s Approach to Addressing Medical Necessity Denials

A hospital’s typical approach to addressing medical necessity denials, DRG down-codes and clinical validation denials is to throw and devote more resources, staff, and acquire more software to manage the onslaught of denials. This approach is a lesson in inefficiencies and futility from the sense the hospital is overlooking and neglecting the addressment of the root cause of these denials, poor and/or insufficient documentation. Claims are placed into this category when the medical documentation submitted is inadequate to support payment for the services billed, as defined by Medicare.  Poor and insufficient spans the gamut from lack of documentation, documentation that adds little if any value to the care of the patient, lack of clarity in documentation, cut and paste of documentation creating issues with situational awareness and carry forwards with concerns of contextual consistency. A contensious area that has a strong tendency to breed DRG down-codes and clinical validation denials is Clinical Documentation Improvement Programs, initiatives heavily ingrained in most hospitals as a means of optimizing inpatient DRG revenue. What Chief Financial Officers fail to realize is that present CDI processes are conduits for denials mainly due to the realized fact that CDI programs were never intended or designed to improve actual documentation. Instead, CDI programs were designed and intended to serve as a band-aid approach to documentation improvement, securing the capture of additional diagnoses and/or clarification of nonspecific diagnoses in the interest of producing “optimal revenue” through the MS-DRG assignment. Optimal DRG assignment translates into case-mix increases that produces enhanced reimbursement for the hospital. Often overlooked by CFOs is the notion that increases in case mix are measured in gross patient revenue versus more accurate and reliable net patient revenue, taking into mounting costly denials and the resources needed to appeal with no assurance of success. The underlying limitations and shortfalls of CDI programs centers on the limited effort and capability of CDI specialists to actually improve physician documentation beyond diagnoses capture through the repetitive transactional reactive query process. What is missing is the general lack of enhancement and improvement of the quality, completeness and accuracy of the physician’s documentation describing, showing and telling the true patient story reflective of the patient’s severity of illness, need for hospital level of care and the potential risks and untoward event to the patient without said hospital level of care. In short, what is required is a clear detailed account of all relevant clinical facts, clinical information and context surrounding the care ordered and/or provided accompanied by clear concise documentation by the physician of his/her clinical judgment, medical decision making and thought processes.

Medical Necessity Denials-A Unique Challenge

Medical necessity denials present unique challenges to mounting a successful effective appeals campaign for lack of supporting clinical documentation in the record. Medicare defines this category of denials as when the contractor reviewers receive adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies. This lack of supporting clinical documentation can be appropriately addressed through transformation of current clinical documentation improvement program processes from one predicated upon transactional reactive processes to one more closely aligned with the revenue cycle that embraces proactivity and a tailored balanced approach to documentation improvement that achieves meaningful measurable positive change in physician overall behavioral patterns of documentation. The crucial first step in driving real improvement in documentation is to reengineer, refocus, redirect and rebrand current CDI efforts, recognizing the urgent need for wholesale directional change in CDI.


Effectively staunching the tide of tremendous revenue leakage associated with increasing medical necessity denials requires a refreshing novel approach that gets to the root cause consisting of poor and insufficient documentation. Medicare under its annual CERT program report highlighting the annual Fee-For-Service Improper Payment Rate consistently identifies insufficient documentation as accounting for the majority of medical necessity denials. The best course of action to mount that will directly address these medical necessity denials is to design, organize, plan and execute a focused strategy for transforming present day CDI initiatives into a program that engages physicians in a participatory manner in truly wanting to improve their communication of patient care for all the right reasons. In my next blog, I will outline the steps necessary to initiate this extremely time sensitive strategy. Time is of the essence as medical necessity denials continue to mount in most healthcare facilities contributing to lost net patient revenue opportunities and increased cost to collect associated with the denials and appeals process.

About the Author

Glenn Krauss is a longtime Revenue Cycle Professional with progressive hands one experience in all facets of the revenue cycle. He possesses a high energy level and passion for clinical documentation improvement initiatives that drive physician engagement in truly wanting to learn and acquire best practice standards of clinical documentation supporting communication of patient care.  He is the creator and founder of Core-CDI.com. 

Myocardial Infarctions

What’s with all the new codes for myocardial infarctions (MI), you may be asking yourself.  What differentiates a type 1 from a type 2 MI?  This edition of “In the kNOW” will delve into those questions and more.

As you have undoubtedly noticed, myocardial infarction codes now allow us to capture the “type” of MI that the patient experiences.  This is very useful as more and more cardiologists had been specifically documenting type 2 MI and leaving us with no way to distinguish that particular type of MI from any other.  1^st Qtr. 2017 Coding Clinic had instructed coders to use I21.4 for a type 2 MI which was the same code as a Non-ST elevation myocardial infarction.  We were instructed to assign the type 2 to NSTEMI unless there was documentation that the MI was a STEMI.  Now, however, we have a specific code, I21.A1, to assign when a patient has suffered a type 2 MI, regardless of whether they are specified as STEMI or NSTEMI.     

So how many different types of MIs are there, and what is the difference between them?  There are five different types of MIs, and they are categorized as follows:

Type 1- MI resulting from plaque rupture or dissection

Type 2- MI that occurs as a result of a supply/demand mismatch

Type 3- A sudden cardiac death, without biomarker evidence of MI, but with signs of ischemia

Type 4:

            Type 4a- MI related to percutaneous coronary intervention (PCI)

            Type 4b- MI related to thrombosis in a stent

            Type 4c- MI related to a restenosis (greater than 50%) post previously successful PCI

Type 5- MI associated with a coronary artery bypass graft

The corresponding ICD-10-CM codes for each type are:

Type 1- I21.9, or code for MI of specific site, or code for STEMI or NSTEMI

Type 2- I21.A1

Type 3- I21.A9

Type 4 (a, b, c) - I21.A9

Type 5- I21.A9

In the event there is an unspecified MI, then assign code I21.9. 

A further word regarding type 2 MIs; because this type of MI results from another condition which is placing the supply/demand of myocardial oxygenation into an imbalance, coders are directed to “Code also the underlying cause, if known and applicable”.   These conditions may include: heart failure, shock, renal failure, anemia, or chronic obstructive pulmonary disease (COPD) to name a few.  The sequencing of the codes would be dependent upon the circumstances of the admission. 

There are “Code first” and “Code also” notes associated with MI types 3-5 which must be followed as well.  The “Code first” note requires code assignment for postprocedural MI if applicable, whereas the “Code also” note is for capturing complications such as stent stenosis or thrombosis.

The expansion of the MI code set also impacts the code assignment for subsequent MIs that occur within four weeks of the initial MI.  Subsequent type 1 and unspecified MIs should be coded from the I22 category and will be coded along with a code from the I21 category with sequencing again dependent on the admission circumstances.  Subsequent type 2 MIs should be assigned to I21.A1, with types 4 and 5 coded to I21.A9.  Note that there would never be a subsequent type 3 MI since that type of MI results in a death.

Now you are in the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

Putting a Proper Perspective on "Proper" Documentation

by Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-CDAM

Proper Documentation is Critical to Our Modern Healthcare System

Proper documentation is indeed critical to our modern healthcare system. The accuracy and completeness of clinical documentation that translates into ICD-10 codes utilized in many distinct roles including quality and outcomes reporting, measures of efficiencies and effectiveness of care, and calculation and determination of value is critical to the entire healthcare delivery model. Clinical documentation improvement programs are purported to “improve” the quality and effectiveness of physician documentation through capture of clinical specificity in diagnoses as well as appropriate capture and reporting of healthcare associated conditions and patient safety indicators. The term “proper documentation” can be defined in a myriad of ways ranging from focus upon diagnoses specificity to the preferred more meaningful approach of communication of the entire picture of patient care longitudinally from initial patient presentation to discharge.

Allen Frady in his article published in in the Journal of AHIMA blog March 29, 2018 titled Proper Documentation is Critical to Our Modern Healthcare System (Proper Documentation Critical) makes several notable points related to the concept of proper documentation. All his points are valid and relevant, raising a few key ideas to consider in the context of proper documentation. Appropriate, concise, consistent and contextually correct clinical documentation is essential from a communication of patient care perspective, serving as a cornerstone for all associated healthcare providers in managing and contributing to the patient’s ongoing care. Potentially bad clinical decisions can be made based upon inaccurate incomplete documentation perpetuated by the advent of the electronic health record and the facilitation of improper copy and paste functionality. A reasonable question is what role can CDI fulfill in achieving proper documentation in the record to the extent the record easily tells the patient story in its entirety? Does the unrelenting focus upon diagnoses capture by CDI accomplish a state of proper documentation? Is CDI as a profession contributing to its fullest potential in the healthcare delivery model with an emphasis confined to the narrowest portion of care consisting of charting of diagnoses. While I certainly am not downplaying the importance of diagnoses reporting, what is far more important, germane and fundamental to patient care is the communication of effective and complete patient care where the ultimate standard is another physician can review the original physician’s note and easily assume care where the original physician left off. If I am a patient in a hospital bed being managed by a hospitalist, the expectation is the nocturnist or the next hospitalist coming on his/her tour of duty can safely assume the continued care of myself. Those involved in day-today CDI can undeniably relate to the current challenges of clinical documentation with carry forwards, copy and paste and inclusion of irrelevant or even worse inaccurate clinical documentation in a progress note that perpetuates and permeates itself throughout the record. Undoubtedly, proper documentation has not been achieved yet with current industry efforts at improving clinical documentation.

Where Does CDI Go from Here?

The first step in CDI promoting, advocating and achieving proper documentation is to outline and define what constitutes proper documentation. Proper documentation is definable in many ways depending upon an individual’s point of view; just the same proper documentation can be defined within the following parameters of the record addresses the following establishment and depiction:

• Right care
• Right time
• Right reason
• Right venue
• Right clinical judgment and medical decision making
• Right rationale plan of care
• Right medical necessity
• Right clinical documentation

A record is properly documented if it accurately, succinctly, completely and effectively tells the patient story. An article titled To Be a Great Physician, You Must Understand the Whole Story (Proper Documentation) puts proper documentation in “proper perspective.” Consider the following key points made by Dr. Robert Centor in the article published MedGenMed:

• Great physicians differ from good physicians because they understand the entire story.
• Each patient represents a story. That story includes their disease, their new problems, their social situation, and their beliefs.
• The story includes making the correct diagnosis or diagnoses.
• The story must describe the patient's context. Who is this patient? What are the patient's goals?
• The great physician understands the patient and the context of that patient's illness.
• Only when physicians understand the complete story do they make consistent diagnoses

A great physician understands the patient and the patient store, effectively documenting the patient story in sufficient depth and breadth where the next physician can easily assume care of the patient. It stands to reason as CDI physician advocates and champions that we assume the high road and transform our tune and respect for proper documentation by truly changing current processes of CDI ingrained in our programs. First, we must recognize the inherent limitations of CDI that constrain achievement of optimal program outcomes and initiate steps to address these significant limitations. In my present role as CDI Manager, I am working diligently and tirelessly to address these handicaps through education and sharing of best practices of CDI with hospital administration, highlighting the material benefits and long term sustainable improvement in clinical documentation reached when one focuses upon achieving documentation that accurately reports and reflects the patient story from time of admission to discharge. This level of documentation, not more documentation but more effective documentation, is the standard CDI should be subscribing to, thereby supporting the diagnoses and associated plan of care arrived at and documented by the physician. Unequivocally, our efforts at clarifying and solidifying diagnostic specificity in the record devoid of documentation that adequately and clearly depicts the patient story frequently leads to outside reviewers refuting the diagnoses of record. Recording of the patient story in sufficient detail inclusive of the context of the patient’s illness and recording of all relevant diagnoses with appropriate specificity should be the standard of CDI promoting and attaining “proper” documentation.

Closing Points for CDI to Ponder

I call your attention to Allen Frady’s closing remarks in his article: “There is an important caveat for those looking to build a successful CDI program: strong administrative support is essential. An emphasis on getting documentation right must come from the top-down, from CMS all the way down to the provider, CDI professional, and, finally, to the coding professional. To get documentation right, it is crucial for the physician to have an open mind and be ready to learn.” Strong administrative support for an effective CDI program implies the program is structured and organized to attain and realize meaningful measurable improvement in documentation. I submit to fellow CDI professionals the duty and responsibility to solicit full administrative support of clinical documentation improvement initiatives for all the right reasons in the name of the patient. Let’s begin by transforming current CDI structures and operational processes to one that supports and facilitates appropriate proper documentation in the communication of patient care.

About the Author

Glenn Krauss is a longtime Revenue Cycle Professional with progressive hands one experience in all facets of the revenue cycle. He possesses a high energy level and passion for clinical documentation improvement initiatives that drive physician engagement in truly wanting to learn and acquire best practice standards of clinical documentation supporting communication of patient care.  He is the creator and founder of Core-CDI.com. 

Key Performance Indicators- Revisited

by Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-CDAM

DI's present-day Key Performance Indicators centered upon reimbursement do not truly reflect a meaningful account of performance in impacting the quality, completeness and effectiveness of medical record documentation. Common KPIs include number of physician queries left, number of queries responded to by the physician, number of queries responded to by the physician that captured a CC or MCC, number of queries responded to by the physician that impacted severity of illness/risk of mortality, number of charts opened and reviewed per day, etc. Examining each KPI individually as well as collectively clearly demonstrate a lack of correlation with measurable improvement in clinical documentation that best communicates the patient care provided. Measurable improvement in clinical documentation adheres to principles outlined in the American College of Physician’s Position Paper-Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper published in January of 2015. Take note of just some of the many credible points made in the article that speak to documentation:

• The medical record was first used by physicians to record their findings and actions and as a vehicle to communicate with other physicians who might care for the patient in the future.
• The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.
• The clinical record should include the patient's story in as much detail as is required to retell the story. 

 

Current CDI Processes-The Necessity for Reengineering

I submit to you that current processes of CDI focusing primarily upon the capture of CCs/MCCs and principal diagnosis optimization fails to address and achieve in any reasonable manner the purpose of clinical documentation as spelled out in the ACP’s Position Statement. As I have always maintained and still champion, reported diagnoses in the record must be surrounded and supported by accurate reporting and reflection of the clinical facts, clinical information and context of the particular case. This means an accurate and complete History & Physical explaining the circumstances of admission to the hospital including a concise yet encompassing History of Present Illness, Patient Chief Complaint in his/her own words, a physical exam congruent with the patient’s nature of presenting problem and the physician’s clinical judgment, a discussion of any abnormal lab values/diagnostic workup results and other pertinent findings and their relationship to the diagnosis outlined in the assessment, and a plan of care congruent with the assessment. Clinical judgment, defined by the physician’s assessment of a particular clinical scenario and the initiation of action congruent with the assessment, is fundamental to the practice of medicine and must be clear in the documentation.

Progress notes are another problematic area where CDI should be focusing its efforts and energy as well beyond mere diagnosis capture that only impacts reimbursement. We are all too familiar with progress notes that lack purpose, substance and validity with the rampant indiscriminate use of cut and paste and carry forwards. Incorrect and inaccurate information is perpetuated throughout the record with questionable contextual consistency. CDI should be promoting, educating, advocating for and achieving progress notes that meet the following conceptual characteristics:

• Factually correct
• Temporally relevant (no future tense references to procedures already done)
• Concise (no fluff; just a concise statement of the facts)
• Devoid of plagiarism
• Analytic– (reflects thoughtful analysis of patient’s diagnosis, status, and treatment options)
• Reflective of collaboration (acknowledges collaboration with house staff, nursing, and other consultants)

  

Encompassing Key Performance Indicator for Progress Notes

A recent article certainly worthy of reading by all CDI specialists recently published in the January 2018 Journal of Hospital Medicine is titled A Prescription for Note Bloat; An Effective Progress Note Template. The article outlines the results of a quality improvement study carried out at four major academic healthcare institutions: University of California Los Angeles (UCLA), University of California San Francisco (UCSF), University of California San Diego (UCSD), and University of Iowa. This clinical documentation quality improvement study combined brief educational conferences directed at house staff and attendings with the implementation of an electronic progress note template. The goal of the study was to determine if progress note quality can positively be impacted and achieved through brief interventions and utilization progress note templates. Note quality was measured using a general impression score; the Validated Physician Documentation Quality Instrument, 9 item version; and a competency questionnaire. What stood out and immediately came to mind was the applicableness of the Physician Documentation Quality Instrument, 9 item version as an instrument the CDI profession could potentially use as a Key Performance Indicator measuring our success in achieving sustainable improvement in clinical documentation. Here is the list of items in the instrument:

• Up-to-date: The note contains the most recent test results and recommendations.
• Accurate: The note is true. It is free of incorrect information.
• Thorough: The note is complete and documents all of the issues of importance to the patient.
• Useful: The note is extremely relevant, providing valuable information and/or analysis.
• Organized: The note is well formed and structured in a way that helps the reader understand the patient’s clinical course.
• Comprehensible: The note is clear, without ambiguity or sections that are difficult to understand.
• Succinct: The note is brief, to the point, and without redundancy.
• Synthesized: The note reflects the author’s understanding of the patient’s status and ability to provide a plan of care.
• Internally consistent: No part of the note ignores or contradicts any other part.

For scoring, one can assign 12.5 points for each item for a total of 100 points with predefined score associated with each point level achieved, i.e., 87.5 correlating to an A, etc.

Time to Rethink Our KPIs

In conclusion, there are numerous Key Performance Indicators that can possibly be used to more accurately reflect and report the achieved successes of CDI in affecting positive change in the quality and completeness of documentation including progress notes.  Good documentation is a fundamental component of high-quality care. The profession alludes to the fact and wants to take credit for improving the reported quality of care in the hospital. Let’s revisit our processes of CDI in the interest of actually improving the quality of care through achievement of consistently sound principles of clinical documentation to complement our efforts at securing diagnoses and optimal reimbursement. Optimal reimbursement is not rooted in longevity and sustainability without optimal clinical

About the Author

Glenn Krauss is a longtime Revenue Cycle Professional with progressive hands one experience in all facets of the revenue cycle. He possesses a high energy level and passion for clinical documentation improvement initiatives that drive physician engagement in truly wanting to learn and acquire best practice standards of clinical documentation supporting communication of patient care.  He is the creator and founder of Core-CDI.com.