By Jocelyn E. Murray, RN, CCDS
There’s no question of the financial sustenance facility case mix index (CMI) provides. An elevated CMI level indicates an increased severity (or acuity weight) in surgical and life sustaining levels of medical care. Facility budgets are formed around the CMI, it is the acuity weight representing the average facility case and therefore reflects upon reimbursement. It makes perfect sense that this marker is a strong point of reference in the financial revenue department and a CFO focus. CMS.gov gives the following description of the CMI: the average DRG weight relative weight calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges.
We know our financial leaders focus on the CMI on an ongoing basis, but is it a true indicator of our CDI operational assessment and program productivity?
In my opinion, the CMI is a good tool to compare area hospital performance at a similar acuity level for medical and surgical care. We know a comparable facility with a much lower CMI can be a direct reflection on missed documentation and lower acuity weighted diagnostic codes. CDI intervention then consists of a provider education plan to improve documentation and capture the severity. Pre-billed audits ensure the acuity is also captured in final coding. Both are standard elements of the CDI process and program interventions.
It can also be a useful tool to help identify how outpatient CDI focus programs in the ED, short-stay surgery, and observation practice levels help ensure CMI accuracy. The DRG for a patient admission that does not meet medical necessity, indicates the patient’s care could have been provided on an outpatient basis. It could also have a critical impact on the CMI.
The lower weight CMI, as reflected by the DRG in this case, is tossed into the bucket as part of the calculated averaged acuity level for the site. One or two occurrences of low CMI weighted inpatient cases may not be a concern, but a handful of cases would certainly have a detrimental overall effect.
In my first years of CDI program implementation, the facility had a significant drop in the CMI over a couple of months during the summer. I dug into the metric further and discovered the top two acuity case surgeons in both neuro and orthopedic were away on vacation. A significant drop in surgeries occurred, and a small number of high-acuity procedure cases were performed and made available in the in that period’s calculation. Of course, the surgeon’s absence had nothing to do with our CDI program productivity efforts. And yet, the CMI drop was brought to my attention by the chief financial officer (CFO) who questioned the cause as CDI productivity. Together, we reviewed my identified findings and took the opportunity to bring forward critical information to the leadership team. The CMI changes had no reflection on the CDI program impact in the absence of surgical caseloads available during that time period.
CDI programs (CDI) are working at more advanced levels in 2017 and need to focus on understanding how their CMI metrics are effected and how the program responds. One key performance of the CDIP is identification of the root cause with any metric change. Only then can you can establish a responsive goal and develop an individualized action plan for intervention.
In my case, a report identified the absence of two key surgeons and the effects of their absence on revenue for the facility. It was then up to the executive leadership and chief medical staff to strategize on how to prepare, plan, and focus actions for this type of revenue impact in the future.
Editor’s Note: Murray is a senior CDI consultant, HIM services, at ComforceHealth. Her subject matter expertise includes consultative CDI services, training and education, and implementation of new programs. She has expertise both in program assessment and enhancement to improve the quality, productivity, and effectiveness of CDI programs within an organization. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board. Contact her at firstname.lastname@example.org.