By Cesar M Limjoco, MD, CMO
(Original article published on LinkedIn, January 17, 2016)
Some time ago, I presented the CDI program to the Medical Executive Committee at a mid-sized hospital. The C-suite stayed after the presentation to discuss implementation details. The chief medical officer wanted to get to the core of what CDI is really all about. He understood from my presentation how it affected resource utilization, level of care, reimbursements, case mix index, facility and provider profiles, quality measurements and patient care; but…
“If a provider documents consistently a diagnosis or diagnoses throughout the patient record, will that suffice?” I responded that it needed to be clinically supported. It should be based on the clinical truth. This resonated with the CMO. He said those words made the best sense and truly put it all together. By George, he got it!
The clinical truth should be the guiding principle for clinical documentation specialists, providers, coders, other ancillary clinicians, case managers and the administration. When our objectives fall short of it, intransigencies occur. It can lead to practices that may not be reflective of the true nature of the patient’s condition. It exposes the facility to audits and denials that are counterproductive, labor intensive, wasteful and ultimately, pricey. When we are guided by the clinical truth — clinical documentation, coding, medical necessity, reimbursement will withstand scrutiny and ultimately improve patient care.