RISE caught up with Amy Campbell, R.N., MSM, CCDS-O, clinical documentation integrity director, Wolters Kluwer, Health Language, one of the speakers at the recent Risk Adjustment Forum, to discuss coding challenges and strategies to improve compliance of clinical documentation.

Campbell, a nurse for more than 30 years in the critical care setting, has built outpatient clinical documentation improvement (CDI) programs across the country, collaborating with and teaching providers, payers, and health information management partners about compliant chronic condition capture. She moved into the tech industry in 2021, joining Wolters Kluwer, Health Language, to help develop clinical natural language processing tools and content for use in risk adjustment clinical diagnosis validation.

Common challenge: The language conundrum

One of the most pervasive challenges that coders and physicians face is that they speak two different languages, Campbell said. A coder’s workflow is based on what is documented in the physician’s note within the medical record. Coders can only code if there is enough information in the record to document a diagnosis. Physicians aren’t taught to code and don’t understand the coding language. Campbell uses the example of a stroke. If the patient had a stroke a week ago, providers may consider that a recent stroke. But for the coder, the patient has a “history of” stroke as soon as he or she leaves the hospital.

This miscommunication not only causes frustration between providers and coders, but it can also become a compliance issue. The Office of Inspector General (OIG) targets areas where there is inconsistency, particularly where communication gaps exist, Campbell said. “They are targeting areas where clinical practice differs from coding practice, including how that coding language works.”

Population health and social determinants of health are two areas that could become compliance concerns, she said. While providers are becoming aware that there are non-medical conditions that impact people’s health and are beginning to ask patients about them, if the information isn’t in the note, the coder can’t code it. “So, providers may be asking questions to get the information, but oftentimes it’s not in a format that the coders have access to,” she said.

This is an example where CDI can be helpful because the clinical documentation specialist has clinical and coding experience and can pull those two languages or two worlds together. The specialist can clinically validate whether a condition exists and if the specificity is in the record to capture the diagnosis.

Common challenge: Physician buy-in

But what if a physician doesn’t believe in the CDI program?

Physicians don’t receive training on clinical documentation in medical school so it’s common for some providers to resist these programs as an added hassle and unnecessary work.

Relationship building is vital before physicians can buy-in to the process, Campbell said. “So much of what I do or have done in the past is relational,” she said. “I need to have a relationship with that provider very similar to when I was caring for the patients, so that they trust that I am going to do what they've ordered me to do. I’m a support person, so to speak. That role doesn't change a whole lot when it comes to CDI. I am still a support person.”

If physicians trust that support person, it’s easier for them to understand that the CDI specialist is there to ensure that the care the patient receives is documented and the query is justified. Where a coder can only look at a singular encounter, a CDI specialist can look elsewhere in the chart to pull out information that may indicate another condition. For example, if a CDI specialist sees a patient is receiving dialysis, he or she can ask the physician, was this an emergency or is this long-term due to end-stage renal disease?

The key, she said, is not to ask leading questions.

The work is not to only find the diagnosis but to find the information in the note that supports that diagnosis, Campbell explained, noting that the validation is also helpful for payers.

“It would help the payer to establish a case for this diagnosis to say, ‘I have the diagnosis here, but then I also have all these clinical indicators that support this diagnosis.’ So, it’s clinically validating that diagnosis, not just data validation where the diagnosis is present.”

Once it’s determined the condition was present in the past and you have supporting information, Campbell said a payer could potentially use it as a basis of a query to the provider to ask whether the condition is still valid or viable. And if that is the case, the payer can ask the physician to please include any valid or viable conditions they addressed in the note for the upcoming visit so that they can better understand the treatment plan or what the provider saw that supported the patient’s diagnoses.

Strategies for compliance

Whether your organization is just thinking about creating a CDI program or struggling with compliance issues, Campbell offers four best practices:

1. Do the pre-work before launching a CDI program: Review a sample of records to find a few areas to focus efforts on for measurable change. Show how improving documentation in these areas would benefit the patient, practice, or population. Educate providers before establishing a program. “They need to understand the administration values their skills and time, but there is value in the program; we need to find a way to work together and work smarter,” she said. “They need to understand that nobody’s asking for them to work harder. Oftentimes that’s their perception. So, it does take a little bit of time.”

2. Find a physician champion: Having a respected physician who understands the goal of the program is “the golden chip” to launching a successful program. This person supports the mission of a CDI program and can promote it to colleagues.

3. Review the record prior to a patient visit: A clinical documentation specialist can review the medical record in advance of the office visit to assess for suspect or outstanding conditions and compliance opportunities. “This prospective view is a little more forward thinking than traditional coding and lends itself to having a more clinical person in the role.”

4. Set up processes: Establish a policy that calls for a CDI specialist to review the bills with targeted codes prior to submission to ensure the  code is appropriate. If there is a question, the CDI specialist can determine if the documentation supports this diagnosis, or not and changes the code as needed. The ultimate goal is to accurately capture the patient’s story and resources provided during their visit within the boundaries of compliant coding.