Most healthcare providers have limited resources, including limited time to develop their own clinical documentation improvement (CDI) tools. The CDI Toolkit provides clinical information, practical information, and a variety of tools in CD-ROM format for easy adaptation or modification in numerous settings.
Complete and accurate documentation is necessary for appropriate financial reimbursement and has a long-lasting effect on physician and hospital quality scores. It is also necessary for public health reporting of disease and procedure outcome measures, including resource utilization. Clinical documentation specialists (CDS) are responsible for ensuring that documentation in the medical record includes complete and accurate, codable, terminology that facilitates accurate calculating and reporting of severity of illness (SOI) and risk of mortality (ROM). Inaccurate and nonspecific documentation leads to inappropriate reimbursement and profiling for providers and hospitals.
The Centers for Medicare & Medicaid Services (CMS) is assessing Medicare spending per beneficiary episode through its value-based purchasing (VBP) initiative. VBP aims to promote high- quality, safe, patient-focused care that avoids preventable adverse events, including healthcare-acquired conditions, while reducing costs.
SOI and ROM calculations based on the interaction of multiple comorbidities and sequencing of diagnoses are the underlying theme of quality reports. Conditions can affect SOI and ROM regardless of whether they are complications and comorbidities (CC) or major complications and comorbidities (MCC).
In this CDI Toolkit the clinical categories reflect the Major Diagnostic Categories, and within each section we have included specific examples of scenarios in which queries are necessary. A facility’s query process must consider etiology of the symptoms and/or disease and disease manifestations and/or consequences.
Increased clarity and specificity is important for accurate coding, but it’s also necessary for an accurate and complete reflection of patient acuity and provider performance.
Queries should seek clarification and specificity. They should not question providers’ clinical judgment. A query is not necessary if there is no clinical support of a diagnosis. Written and verbal queries that may be construed as leading providers are impermissible. Queries that appear to prompt a particular response are similarly impermissible.
Queries should present the facts in the current medical record. They should not introduce new information or information not in the current medical record. Query forms should not be designed so that only a signature is required. The same standards should apply regardless of whether a query is part of the permanent record. Additionally, diagnoses should be carried throughout a medical record and not appear only on a query.
Audits should be a part of any facility’s ongoing monitoring of its CDI program. Sample audit suggestions included in various chapters serve as an exploratory tool for non-punitive and process improvement opportunities.
Review your facility’s Short-Term, Acute-Care Program for Evaluating Payment Patterns Electronic Report (ST PEPPER) to determine whether an audit for medical necessity and/or coding is necessary. TMF Health Quality Institute develops and distributes ST PEPPER under contract with CMS. This report isn’t necessarily indicative of a problem; it provides benchmark data that compares a facility with other facilities.
If resources and time permit, consider a more formal random sampling. If resources and time are limited, consider a focused review of suspected problematic issues of concern nationwide, identified in your ST PEPPER report or through your denial management program. Consider monitoring one of your audit focuses during the first quarter (e.g., October–December), changing processes and implementing changes during the second quarter (January–March), and re-monitoring during the third quarter (April–June). Another audit could be monitored January–March, changes implemented April–June, and re-monitored July–September.
Consider self-audits during which clinical documentation staff compare their queries to the organization’s query policy and practice. CDI managers should conduct staff query audits for compliance monitoring. Managers also should audit cases with only one additional International Classification of Diseases code after the principal diagnosis code. Learning from others internally and externally through networking and national association membership is important.
Collaborate internally with the following colleagues:
- Providers (e.g., attending and consulting physicians, pathologists, radiologists, anesthesiologists, emergency department physicians, psychiatrists)
- Physician assistants and advanced practice nurses
- Non-providers (e.g., nurses, patient care technicians, dietitians, speech therapists, rehabilitative therapists, quality staff, laboratory, infection control, utilization, care management, risk management, dialysis, emergency department)
Collaborate with your medical records and forms committees and provide input regarding language included in any form that may directly or indirectly affect codable documentation. Expand your CDI steering committee to include multidisciplinary representation.
Externally collaborate with CDS’ locally, statewide, and nationally. Attend conferences, meet colleagues, and continue relationships post conference. Be open to new ideas and approaches. Be willing to share with others for the betterment of the profession.
Editor’s Note: This post is an excerpt from the introduction of The CDI Toolkit written by Nancy Rae Ignatowicz, RN, BS, MBA, CCDS. The CDI Toolkit contains sample queries, powerpoint presentations, educational materials, and other items to help CDI specialists advance their programs.
Editor’s Note: There is a lot of discussion in the industry of late regarding the ongoing and increasing importance of CDI program implementation to meet the challenges of ICD-10 implementation, value-base purchasing, public quality reporting and other changes in healthcare. Those hospitals that have not made the investment yet should consider the following information taken from the ACDIS CDI Roadmap which outlines Phase I of CDI program implementation. The Roadmap is free to ACDIS members and includes a number of sample tools and materials.
Assemble a steering committee (SC) to include the following:
- Health information management (HIM) director
- Chief financial officer
- Information services (lead application developer or manager, to discuss the hospital’s capacities to track data)
- Data analysis/management (to develop and run detailed reports for pre-program baseline analysis)
- Chief medical officer or vice president (VP) medical administrator
- Case management director
- Director/VP of quality
- Director/VP of compliance
- Medical staff secretary (ad hoc member)
- Compliance (ad hoc member)
Have the SC meet and assign individual responsibilities.
Schedule weekly SC meetings until start of program to keep project moving forward and everyone on task. See “Project Assessment Template”.
Develop project plans
- Develop program objectives/purpose. Include physician input when developing objectives/purpose to ensure buy-in and engagement at the earliest stages. (See sample documents “Goals and objectives of CDI”, and “Basic CDI Presentation”)
- Determine if outside support is needed (i.e., external consulting company).
- Determine budget for program startup. Consider initial year salaries, infrastructure, consultant (if needed), training, software, and other necessary equipment.
- Determine projected annual budget for program. Consider salaries, technical support, education, certification, and ACDIS membership.
- Determine reporting structure for CDI program and staff.
- Determine structure and communication process for CDI and coding (i.e., how CDI staff will communicate with coders to resolve DRG assignments).
- Determine medical staff responsibilities and accountability (i.e., time frame for query responses).
- Develop physician overview/education and tools. (Note: Include physician input during this process.)
- Develop a CDI 101 presentation for docs, including both positive consequences of good documentation (i.e., how it helps their reimbursement, public profiles, and E/M payments, and reflects patient severity of illness), and negative consequences of poor documentation (i.e., down-coding, denied E/M payments, denied stays, CERT reviews, RAC take-backs). (See sample documents “CDI 101 for docs”, “CDI 101 for docs 2″, “CDI new resident orientation presentation”, and “CDI Week video”.
- Provide examples of slides demonstrating the value of documentation (inpatient and outpatient) and its direct correlation to hospital and physician data.
- Develop preprogram education plan (how to train new CDI staff, who will provide training).
- Request broad baseline data from HIM, patient financial services, and case management (i.e., case mix index, number of discharges, unpaid claims, denials from commercial payers, Recovery Auditor denials) to determine pain points.
- Determine start date of program.
What does the government say about the use of physician queries? Not much, actually. In fact, CM has remained relatively mute on the matter since 2001 when it stated in a memorandum to Quality Improvement Organizations that
“Use of the physician query form is permissible to the extent it provides clarification and is consistent with other medical record documentation.”
In essence, CMS concluded that query forms are primarily a communication and education tool rather than actual medical record documentation. CMS deferred the promulgation of specific guidelines addressing the practices associated with physician query forms to HIM experts and healthcare entities. CMS further stated that a query form should not be leading, nor should it introduce new information not otherwise contained in the medical record. TMF Quality Institute (a Medicare QUI for Texas) cites that CMS instructed QIOs to refer cases to a QIO physician reviewer for evaluation if the physician query form is leading in nature or if it introduces new information.
Editor’s Note: In the absence of additional guidance from government regulatory bodies, AHIMA stepped forward to publish a number of documents to guide professional through the query process. These include:
- Guidance for Clinical Documentation Improvement Programs
- Clinical Documentation Improvement Toolkit
- Managing an Effective Query Process
This excerpt is from The Physician Queries Handbook: Guide to Compliant and Effective Communication.
Whether the query contains multiple questions on a single form or is a multiple-choice query, be sure to compose the questions clearly. The query form should be concise and should offer easy-to-answer questions. If the physician needs to read the form more than once to understand the question, he or she most likely will not take the time to do so. Rewrite the form; ask yourself the question as if you were the physician in order to analyze the ease of the interpretation.
Track physician responses by “agreed,” “disagreed,” “answered, but not clearly,” or “no response.” Identify any further explanations the physician provides regarding his or her responses. It could be the form itself, the duplication of the same or similar questions, the way the specialist asked the question, or the content of the question itself. Monitor the responses by physician, by subject, and by CDI specialist. This will provide a good base for the CDI program to judge its effectiveness.
When writing free-text questions, remember to be brief and to the point. Avoid improper grammar and incomplete sentences. A physician may discount the intelligence of the query unless the physician can clearly identify the objective. Use “please” and “thank you.” Everyone likes to hear these words.
Try to avoid any diagnostic indications but provide objective clinical information and documentation from the medical record, referencing a chart documentation issue. Address the document and date where the issue was found. Ensure that the physician understands why the question is being asked. The physician will not cooperate if he or she thinks that you as the coder or CDI specialist are trying to practice medicine or contrive unsupported diagnoses. In addition, avoid putting the answer you want in the title of the query form. Do not label your forms with descriptors such as “sepsis” or “acute kidney injury.”
Editor’s Note: ACDIS and AHIMA are currently working on a joint physician query guidance report expected to be released in 2013. This excerpt is from The Physician Queries Handbook: Guide to Compliant and Effective Communication.
An average rule of thumb is for a CDI program to employ one CDI specialist for every 1,250 to 1,500 discharges per year. Most facilities (46%) of the nearly 500 respondents to the 2010 CDI Program Structure Benchmarking Report said they employ between two and four full-time equivalent (FTE) staff members, 23% employ only one FTE, and 14% employ between five and seven staff members.
Consider higher staff ratios for programs that expect CDI specialists to perform multiple functions (core measures review, utilization management, quality reviews, or concurrent coding, for example) and a lower ratio for program that perform condition clarifications only. Other considerations include the amount of vacation time staff have available; programs which hire tenured CDI staff may have to adjust for higher weeks of vacation availability. As program expectations change, review staffing requirements to ensure that existing staff can accomplish the new goals with the resources available.
In general, a dedicated CDI specialist should have an average daily census of 12-15 new patients and between five and 10 established and follow-up cases. This census will allow for appropriate query follow-up and daily reconciliation of discharged cases. Therefore, the decision of how many new staff members to hire can be made by dividing the average daily census by 15. CDI leaders can further quantify that number by obtaining the average daily admission numbers.
Another variable to consider is if the CDI specialist is allowed to determine at what point they stop reviewing a case of if they are required to re-review the case periodically until discharge. This can also have an impact on number of cases per CDI staff member.
Editor’s Note: This excerpt comes from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition by Marion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS.
When determining who to hire as CDI specialists, the facility needs to remember a number of additional factors specific to the CDI role. For example, staff must have strong cross-disciplinary awareness. If coders are used they must have str5ong clinical knowledge. If nurses are used, they must have an understanding of the basic tenets of coding and coding guidelines. In addition, the CDI team members must be willing to embrace opportunities to grow from others on the team with different backgrounds.
Whether a facility uses coders, nurses, or some combination of both, and regardless of to whom the CDI staff reports the goal of capturing complete and accurate documentation should not be compromised in favor of other agenda. Without clearly defined responsibilities, a case manager who also performs some CDI tasks may push one set of responsibilities aside for another given the limitations of time, experience, and administrative expectations. Conversely, a coder might not pursue a query if tasked with concurrently coding a chart, meeting productivity standards, and maintaining discharged not final billed goals.
Editor’s Note: This excerpt comes from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition by Marion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS
Engage the physician in query development
Experienced CDI programs often suggest that the best form of physician education is physician involvement. The earlier physicians get involved in the development of the CDI program, the greater their investment becomes. With the program parameters established, CDI staff can turn their attention to the development of physician query templates.
The medical staff most closely linked to a particular condition should vet the clinical guidelines incorporated in the query forms. For example, many facilities have clinical guidelines to help determine types of congestive heart failure based on recent medical literature and as supported by the cardiology department.
The American Hospital Association’s Coding Clinic for ICD-9-CM supports the development of guidelines for querying physicians. It states:
Facilities can work together with their medical staff to develop facility-specific coding guidelines, which promote complete documentation needed for consistent coding assignment. … These facility guidelines must not conflict with the Official ICD-9-CM Guidelines for Coding and Reporting developed by the Cooperating Parties and additionally they should not be developed to replace the physician documentation needed to support code assignment.
Further, the ICD-9-CM Official Guidelines for Coding and Reporting state:
A joint effort between the healthcare provider and the coding professional is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized.
Physicians are not the enemy. Despite how busy they are, they want to comply. They want positive feedback. They want to do the best job they can for their facility and, perhaps more importantly, for their patients.
Editor’s Note: This post is an excerpt from The Physician Documentation Improvement Pocket Guide instruction manual. The Physician Documentation Improvement Pocket Guide, by Pamela P. Bensen, MD, MS, FACEP, is a tri-fold laminated card which comes in packs of 25, to assist CDI specialists in their physician education efforts.
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|
Developing a facility-wide master plan represents best practice in all forms of business. the same holds true when implementing a CDI program. The CDI master plan, complete with mission and vision statements, serves to concisely define the purpose and goals of the program. Implementation of a CDI program is, after all, a piece of the overall complex healthcare enterprise, and therefore, the decision to initiate a CDI program should coincide with the facility’s overall mission.
The steering committee should discuss how the facility’s mission can be enhanced by the addition of the CDI program and then create a specific statement for the CDI team. Be sure this mission and vision are unanimously supported and approved by the larger facility administration. An existing program without these statements should consider raising the concern during upcoming administrative meetings and incorporating it into its policies and procedures.
In simplest form, the vision of a CDI program should be to promote precise and accurate clinical documentation throughout the medical record using compliant methodologies, which will result in appropriate and accurate code/MS-DRG assignment, patient quality measures, and reimbursement for care rendered.
Obviously, additional themes may be added to the CDI mission and vision statements to address specific issues. For example, establishing a cohesive communication line between clinical and coding staffs might be an appropriate addition for a facility that traditionally struggles with cross-department dialogue. If, as part of its overall corporate vision statement, a facility declares itself as the “the place where quality care means caring about quality,” the CDI department may add this sentiment to its vision statement as well by stating: “The CDI staff strives to ensure quality documentation within the medical record reflective of the quality of care provided.”
Make sure this vision supports the desires of the various stakeholders in the CDI process. This mission statement should not be generated by an administrator is an third-floor office. Ensuring steering committee members help formulate the program vision guarantees they also understand the vital role their departments play and the interdependency of those roles. Such awareness helps different departments feel a sense of ownership in the program and its accomplishments. It also enables the different department leaders to communicate that understanding to their respective staff members.
Editor’s Note: This except was taken from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition.
What is the basis of medical necessity? According to TrailBlazer Health Enterprises:
“Medical necessity is based on the following attributes of the service that affected the physician’s documented work:
- Number, acuity and severity/duration of problems addressed through history, physical and medical decision-making.
- The context of the encounter among all other services previously rendered for the same problem.
- Complexity of documented comorbidities that clearly influenced physician work.
- Physician scope encompassed by the problems (number of physician systems affected by the problems.”
Consider how this affects the role and function of CDI professionals. Other than distinguishing diagnoses from symptoms and addressing other previously discussed clinical clarifications, CDI professionals generally don’t focus on the number acuity, and severity/duration of problems addressed with the history and physical, history of present illness, and medical decision-making. Accurate acuity of diagnosis reporting (e.g., congestive heart failure [CHF] or acute systolic CHF) remains at the top of the clinical clarification agenda.
CDI specialists should also focus on the severity and duration of problems and diagnoses documented in the medical record to emphasize the need to illustrate the medical necessity of physician and hospital evaluation and management (E/M) services.
Editor’s Note: This excerpt is from The Documentation Improvement Guide to Physician E/M by Glenn Krauss, BBA, RHIA, CCS, CCD-P, CCDS, independent healthcare consultant based in Madison, WI.