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When I post on twitter about CDI, I often get comments saying, “This is a waste of my time. How does this actually help my patients?” Even worse, some say I’m promoting fraud.

Let’s talk about that.

CDI stands for Clinical Documentation Integrity. It’s about ensuring the information in notes is as accurate and complete to the highest degree of specificity possible. While this may seem like an obvious requirement to those outside of medicine, those of us in healthcare know that obtaining that goal almost seems like an insurmountable problem.

CDI often gets a bad rap for “focusing on improving reimbursement” because…well…that’s a side effect of complete and accurate documentation. But, the language physicians typically use isn’t 100% congruent with coding language. That’s where CDI sits as a bridge. Connect that bridge and reimbursement falls where it should.

Persistent Atrial Fibrillation

A patient presented with Afib with RVR. The ER called Cardiology:

"Admit for Diltiazem drip, TEE / cardioversion in the AM" they told the ED doc.

After digging in the chart, I notified the cardiologist that the patient actually had PERSISTENT atrial fibrillation. "Oh...

Increase metoprolol. Discharge from ER. Will see in clinic tomorrow."

The problem?

"Paroxysmal Atrial fibrillation" was all over the chart.

But was incorrect.

Paroxysmal atrial fibrillation means the patient is in and out of Afib. If they are currently having an episode of Afib with RVR, then that is an acute episode which should be managed acutely, often with a rhythm-control strategy (trying to get them OUT of Afib). However, persistent atrial fibrillation means the patient is persistently in Afib. Many of these patients are instead managed with a rate-control strategy - meaning we try to keep their heart rate about less than 100 instead of trying to get them OUT of Afib.

Paroxysmal Afib is not a CC. Persistent Afib is a CC. That is often the focus of CDI discussions, but you can see here that having it accurately documented and recognized directly impacts management.

(Go here if you’re unsure what CC’s and MCC’s are)

Previous L MCA ischemic stroke with residual right hemiparesis

A new admit arrives to the floor and the nurse notes new R sided hemiparesis. A rapid response is called. The covering physician confirms the R hemiparesis. A review of the admission H&P and previous documentation shows a non-focal exam, “moving all extremities well,” and no history of baseline hemiparesis.

A code stroke is called and a stat CT head and CTA head and neck is performed. Fortunately, before thrombolytics are administered, it’s discovered that the patient’s weakness is baseline.

Again, “Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side” is a CC. But that’s not the point here. Consistent and accurate documentation of that diagnosis could have prevented the patient from receiving unnecessary radiation and contrast. This story also highlight’s the importance of your documented physical exam.

Chronic Respiratory Failure with Hypoxia

A patient was admitted with pneumonia and acute respiratory failure with hypoxia. After 4 days, though the patient had clinically improved, the care team was unable to wean the patient off completely off 2L NC and therefore the patient remained in the hospital another night.

The following day, the patient mentioned that they actually wear 2L supplemental oxygen at home.

Could simply talking to the patient have prevented that unnecessary night in the hospital? Absolutely, but so could have persistent documentation of chronic respiratory failure with hypoxia (so that it was front-and-center for the entire care team to see rather than buried in the chart somewhere).

Yes, Chronic Respiratory Failure with Hypoxia is a CC (and acute on chronic an MCC).

Chronic Systolic Heart failure (LVEF 25%)

A patient was admitted to the hospital, given multiple IVF boluses and then placed on “maintenance” fluids overnight. The following morning, the patient developed respiratory distress with a new and rapidly rising oxygen requirement.

The problem? The patient had systolic heart failure with an LVEF of 25% and the fluids quickly sent them into acute pulmonary edema.

This is, by far, the most overlooked and incorrectly documented diagnosis I encounter on a weekly basis. This seems strange as it’s such a black / white problem. However, despite an echo demonstrating a reduced EF, the documentation of heart failure often simply never makes it to anyone’s note. Or it’s documented as diastolic heart failure when the echo shows a reduced LVEF.

It’s such an issue that it’s one of my top recommendations for staying organized during admissions:

Hemiplegic Migraine

A patient is admitted with acute hemiplegia. The presumptive admitting diagnosis is a stroke. “Acute CVA” is listed as the problem. Below that problem is where the physician updates their daily plan.

But further work-up is negative for a stroke and is more consistent with a hemiplegic migraine. However, “Acute CVA” along with the plan to “continue asa/statin” is copy / pasted through to discharge.

A busy PCP, whose already behind in clinic, reviews your discharge summary right before seeing the patient. They talk to the patient about their stroke, and about taking their aspirin and statin, etc. The patient gets confused because they thought they didn’t have a stroke. With the patient in the room, the PCP logs into the computer, digs through the charts, and eventually finds the correct information. The patient gets upset with the PCP and storms out of the office yelling, “you people don’t know what you’re doing!”

Sure, maybe not a medical error. But was that interaction ideal? The PCP is even more behind now and this may cause them to make a medical error on another patient. And how much did that interaction contribute to the PCP’s burnout? All of this could have been prevented by simply updating the discharging diagnosis.

This story highlights the importance of reviewing the final problem list for accuracy, preventing copy / paste inaccuracies, and the significance of a good discharge summary.

Your notes aren’t just words on a screen.

They’re not just billing receipts.

Good documentation is accurate, complete, specific and up to date documentation.

Good documentation is good patient care.

Notes have direct, and indirect, impacts on our patients, ourselves, our colleagues and our hospitals. We must recognize this by taking ownership and by being stewards of our notes.

That’s all for now. I hope that was helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

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