Some feel establishing goals based solely on reimbursement leads to compliance concerns. Others assert accurate documentation of the care a patient receives naturally leads to improved reimbursement and tracking it just helps support the need for the CDI program. Regardless, the financial return on a facility’s investment in its CDI staff is undoubtedly beneficial information to help prove the value of the CDI program, especially in the current healthcare environment where every expense and departmental budget is scrutinized.
Conveying the financial benefits of CDI can be fairly easy; the addition of a single complication or comorbidity (CC) or major CC (MCC) can shift the designation of patient care into a higher weighted diagnosis related group (DRG), thereby increasing a facility’s reimbursement by thousands of dollars.
For example, if a patient who suffered a heart attack requires surgery for a pacemaker and lead implant the principal diagnosis would be coded 410.01, acute myocardial infarction of other inferior wall, initial episode of care, and the procedures would be coded 37.72 (initial insertion of trans venous [pacemaker] leads [electrodes] into atrium and ventricle) and 37.83 (initial insertion of dual-chamber [pacemaker] device). At the time of admission, the patient is noted to have a history of congestive heart failure (CHF) and the chest x-ray in the emergency room showed venous congestion, which improved after the administration of Lasix intravenous push (IVP). The medication record indicates Lasix 40 mg IVP was given twice in the emergency room.
The figure below illustrates how different ICD9-CM codes roughly translate into MS-DRG codes and the estimated payment changes associated with such differences.
Employ caution, however, when illustrating the CDI program’s affect on reimbursement. While improved capture of clinical documentation may increase reimbursement, it may not always do so, and creating a CDI program for financial gain cannot be the program’s only purpose. Money earned from inappropriate means today is simply money taken back–with interest–by the government later.
Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition, by Marion Kruse, MBA, RN, and Heather Taillon, RHIA.
|428.0, Congestive heart failure, unspecified||244, Permanent cardiac pacemaker implant w/o CC/MCC||$11,510|
|428.0 and 428.32, Chronic diastolic heart failure||243, Permanent cardiac pacemaker implant w/CC||$13,728|
|428.0 and 428.33, Acute on chronic diastolic heart failure||242, Permanent cardiac pacemaker implant w/MCC||$17,554|