How to Establish a Clinical Documentation Improvement Program

For years, home health agencies (HHAs) have been conducting many of the components of a Clinical Documentation Improvement (CDI) program—but they may not have heard it labelled as such. Of course, documentation review, with its goal of improvement, has always been a priority for agencies. Pieces of the program are usually distributed among many roles in the agency office, typically including clinical managers, quality assurance and performance improvement (QAPI) coordinators, coders and/or the billing department.     

CDI is a formal program or initiative across health care with certifications in various settings, including acute care hospitals. Documentation is key to compliance and reimbursement across the health care continuum.

Never could this be more true in home health, as increased audits by the Centers for Medicare & Medicaid Services’ Medicare Administrative Contractors and third-party contractors have led to a high number of denials that can threaten the viability of agencies. CDI focuses on key areas of Medicare eligibility and compliance, including the face-to-face and skilled need categories—areas that can impact denials.

In addition, increased numbers of condition-level deficiencies and immediate jeopardy resulting from regulatory surveys—which can lead to sanctions—have been occurring in home health. Some problematic conditions of participation (CoPs) are patient rights, QAPI, infection control, care planning, coordination of care and quality of care and aide services.

CDI & QAPI

QAPI focuses on improving patient outcomes. Using data from the Certification and Survey Provider Enhanced Reports OASIS outcomes, Home Health Compare and the Consumer Assessment of Healthcare Providers and Systems will allow an HHA to develop a plan to improve patient outcomes that will include compliant documentation.

Therefore, QAPI and CDI can work well together. A goal of QAPI and CDI is to have continued survey readiness so that no matter when a surveyor comes to visit your agency, your documentation can withstand scrutiny.

While a formal QAPI program is often based on the quarterly review of a percentage of records, CDI can implement real-time processes and audits to prevent problems from occurring in documentation. Also, CDI focuses on preventing denials. Together, QAPI and CDI can help keep HHAs compliant.

CDI & PDGM

The Patient Driven Groupings Model (PDGM) relies heavily on clinical characteristics to place home health periods of care into payment categories. Therapy visit thresholds for reimbursement have been eliminated, emphasizing therapy as part of the interdisciplinary team. Documentation showing that outcomes are improved, especially with fewer visits than before, will be key.

Under PDGM, the patient’s primary diagnosis is a key driver for reimbursement. There are many common home health diagnoses that can no longer be used as a primary diagnosis. In addition, there can now be up to 24 comorbidities or secondary diagnoses that will factor into reimbursement, and OASIS items (such as activities of daily living, instrumental activities of daily living and hospitalization risk) lead to a functional impairment level of low, medium or high. Ensuring that the plan of care, comprehensive OASIS assessments and visit documentation support the primary diagnosis is essential; processes to ensure timely, accurate and complete documentation are key components of CDI.

Justifying Need

There is more scrutiny of the need for improved documentation to support the need for services. Upon referral to home health, determining whether the face-to-face encounter (FTF) meets Medicare qualifiers is crucial.

Therefore, CDI must start at the referral. The referral information must include details identifying the patient’s needs. If the referral has an unacceptable primary diagnosis, a query to the physician must be made, because an acceptable PDGM primary diagnosis must be on the referral and the FTF in order to qualify for a Medicare home health admission.

If Medicare eligibility remains questionable at the point of referral, an initial assessment should be completed prior to the comprehensive assessment in order to ascertain whether a patient is eligible for home health care. This is a process that the CDI staffer should be involved with, as it is often a weak area and can lead to denials.

Decrease Deficiencies & Denials

The CDI program will ensure that the clinical record review includes such areas as:

• There is an order for every visit performed.
• Each visit note stands alone to show a skilled service provided; they must also tell the patient’s story.
• Visit notes include the assessment, skill provided, patient or caregiver response, plan for next visit and need for skilled services and complexity.
• Coordination of care between the interdisciplinary team is well documented throughout the patient’s home health clinical record.
• The physician is notified of all patient changes. This is critical, as lack of physician notification is a key reason for negative outcomes and condition-level deficiencies or immediate jeopardy.
• Medical necessity is clearly documented by skilled nursing and therapy.
• Homebound status is documented and supported in the clinical assessment.

The CDI will ensure that the focus of the documentation states:

• Why are you providing the services?
• What interventions and teaching are you doing?
• Why is home health necessary?

The CDI will also ensure that the documentation states why you’re providing the services, what interventions you are doing and why home health is necessary. It should also focus on common denial reasons, such as:

• Skilled services not reasonable and necessary
• Repetitive and unclear notes that do not show a skilled service provided
• Therapy assessments that indicate the patient is independent when describing levels of assistance
• Documentation does not support homebound status
• Goals not objective, measurable or reasonable for patient
• Progress toward goals not documented

CDI Strategies

It is important to review data and perform analysis on clinical performance with quality metrics. A key CDI methodology that I have found to be very successful is concurrent ongoing clinical record review. A team of qualified reviewers, including trained field clinicians, reviews records from referral through final claim at least once a week so reviews are near enough to real time to catch and correct issues. 

Since reviews are frequent, they can be done quickly. The goal is to identify whether corrections from previous review timepoints were completed and to review all new documentation since the last review and note deficiencies. One audit tool per patient is used throughout the entire admission process, and there can be several reviewers.

While QAPI will review a percentage of records quarterly, CDI will review much more frequently on active patients in order to prevent denials and deficiencies.

It is then possible to identify non-compliant documentation according to team, clinician and agency. Education can be tailored to a few clinicians rather than delivered to the entire group.

And using field clinicians on the review team means peer review—an effective method of engaging staff in the CDI process.

Building a CDI Program

Creating a CDI task force or committee is helpful. It is important to include all departments such as leadership, billing, coding, QAPI and office staff. The project leader is the identified CDI professional.

The task force can develop priorities and goals for the agency, such as:

• Decrease denials: Be specific; list the reason for denial, the percentage and the areas of focus (referral, FTF, skilled need, etc.)
• Avoid condition-level deficiencies: Explain in which CoPs you will do this and how
• Identify areas of risk within the agency for documentation inaccuracy, reimbursement and non-compliance with CoPs by reviewing past deficiencies and denials and areas found during clinical record reviews
• Manage inefficient agency processes that lead to non-compliance, such as signed physician orders

An effective CDI program will typically indicate the need for education for home health staff. Home health documentation is not easy, and staff are held to productivity standards and caring for their patients, so don’t get frustrated when frequent education is required to have compliant documentation.

In Conclusion

In this era of home health—with the Patient Driven Groupings Model, value-based purchasing, audits and more—robust documentation is required. Many denials stem from improper documentation by agency clinicians who thought they were following coverage guidelines. And many more deficiencies are being seen on surveys under the new CoPs.

If you don’t have a Clinical Documentation Improvement Program, consider implementing the key elements. A CDI program can help an agency remain viable for the future.