Physician support in the CDI decision-making process from the CDI program’s inception helps physicians see beyond the immediate obligation of documentation to the greater good such documentation provides.
Physicians, as a group, tend to have similar personality traits. For example, physicians are:
- Educated, so give them definitions
- Scientists, so give them data
- Proud, so illustrate how they rate against their peers
- Results oriented, so give them a goal
Many argue that the best form of physician education is physician involvement. The earlier physicians get involved in CDI development, the greater their investment becomes. At the CDI program’s inception, medical staff leadership or the facility’s chief medical officer (CMO) typically join the CDI steering committee to set overall goals from the program and expectations for physician response, involvement, and training. Physician investment in CDI at the highest levels trickles down through the physician ranks and encourages the involvement of the entire medical staff in day-to-day documentation improvement activities.
Many programs hire a physician advisor to act as a mediator between medical staff and CDI professionals. If your program has a physician advisor, tap into his or her experience. He or she often plays an important role in identifying CDI targets and providing both group and one-on-one education.
Editor’s note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.
By Jackie Birmingham, RN, BSN, MS, CMAC
Editor’s note: For more information, see Discharge Planning Guide: Tools for Compliance, Fourth Edition, by Jackie Birmingham, RN, BSN, MS, CMAC. This excerpt originally appeared in Revenue Cycle Advisor, here.
Whether writing a note, completing a flow sheet, or entering information in an electronic record, a discharge planner is capturing data: facts related to actions, reactions, and decisions. For the purposes of this example, a discharge planner is writing the story about the planning that occurs to prepare for a patient’s transition to the next level of care.
Information entered into the medical record describes the final discharge plan for the patient. Organizations implement documentation policies to guide discharge planners regarding what the medical record must include.
The Conditions of Participation (CoPs) require documentation of the assessment or evaluation of a patient’s discharge planning needs. CDI specialists can use the following CoPs (c) Standard (c) to ensure the minimum evaluation topics are documented including
- “Admitting diagnosis or reason for registration;
- Relevant comorbidities and past medical and surgical history;
- Anticipated ongoing care needs post-discharge;
- Readmission risk;
- Relevant psychosocial history;
- Communication needs, including language barriers, diminished eyesight and hearing, and self-reported literacy of the patient, patient’s representative or caregiver/support person(s), as applicable;
- Patient’s access to non-health care services and community-based care providers; and
- Patient’s goals and treatment preferences”
The list above reflects the minimum standards. Discharge planners should use this list as a tool to audit a sample of patient charts to determine whether their hospital meets these minimum requirements. After completing an audit, compare the findings to the facility’s documentation policy to determine whether it addresses all necessary elements. Use this activity as an opportunity to identify potential quality improvement initiatives. Although this list aims to aid in assisting in patient discharge needs, CDI specialists can look to these notes to identify additional documentation improvement opportunities or for evidence supporting the need for a physician query. Additionally, CDI specialists should be aware of the wide variety of documentation required throughout the patient’s care, what each documentation requirement’s purpose may be, and the parties responsible for ensuring the accuracy of those documents.
by Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS
The coding function would not exist if there were no physician documentation from which to code. The challenge for coders is not so much that there is no physician documentation; it’s that the documentation they have does not provide them with what they need to assign an accurate and specific code.
The reason for this is that the physician is capturing the clinical nuggets he or she needs. “The physician mind is focused on the associated process of evaluating, treating, and managing the health conditions presented by each patient. The chart documentation provided by the physician is all framed in the language of diagnostic phrasing and language, and [that language] certainly is not about codes,” (Insights from the HCC, n.d.).
Many hospitals have implemented clinical documentation programs to coach physicians on the documentation elements required for the hospital to optimize its coding efforts. However, if physicians don’t feel they or their patients benefit from efforts to alter documentation practices, they quickly disengage. Physicians are accustomed to being paid by their evaluation and management level, not their diagnoses.
Thus, the lack of precision of documented conditions, such as pancreatitis without specifying whether acute, idiopathic, alcohol-induced, sclerotic, or not indicating length of laceration or use of anesthetic or even providing details without a diagnosis (e.g., glomerular filtration range provided to indicate stage of kidney disease) is not unexpected, according to Lucyk et. al. from the University of Calgary (Lucyk, Tang, & Quan, 2016). No, it’s not just a United States problem.
At the office
For the physician practice, the superbill, or encounter form, often contributes to incomplete, unspecified, and inaccurate coding. The superbill often lists the most common diagnoses seen in the practice.
Conditions treated may be forced into those listed on the form or not captured at all. If the physician documents the condition, it may be generic (e.g., asthma, without indication of whether it’s intermittent, persistent, mild, moderate, or severe). In preparation for ICD-10, many practices took the convenient route and selected the unspecified code for each of their most common diagnoses. Therefore, the more specific ones are not on the form to be selected.
Even if the physician uses the electronic health record (EHR) for diagnosis selection, when a long list of choices appears for the condition, it is unlikely that the physician will take the 30–60 seconds to glance down the list to find the specific one; worse yet, the condition that previously had a code may no longer have one (e.g., accelerated hypertension). The physician may believe that for the current state, diagnoses may not be needed for reimbursement purposes, but that’s short term thinking.
Helping the physician help us
For the physician practice, if we desire details, we need to push some of the responsibility out to others in the practice. It should start at the front desk when the appointment is made and the health questionnaire is returned from the patient. That is when, at minimum, duration or date of onset can be obtained.
There’s value in using the medical assistant (MA) to help with securing some of the diagnosis details needed for ICD-10 and augmenting the physician’s efforts. MAs are typically members of the physician office team. If certified, these individuals have completed a structured education program with courses in anatomy, medical terminology, coding, and disease processes. Physicians can benefit from the talents of their MAs and possibly in areas other than ICD-10.
They are one of the first clinical team members to speak with the patient, often collecting the patient’s initial history information, capturing specimens for lab tests, and in some states placing, initiating an IV, and administering IV medications. Since organizations are struggling with capturing start and stop times for IV infusions, perhaps the MA may be another option for capturing start and stop times.
Given their understanding of medical terminology, and with an orientation to ICD-10 code requirements, MAs can quiz the patient and capture some of the details often overlooked by physicians. MAs can save physicians time, supplement the physician’s documentation, and help the physician select a more specific code.
If we look at the ICD-10 injury code elements, most of the elements can be captured in whole or in part by the MA in a short interview with the patient:
- What was the injury? The MA can query the patient for this information and capture “upper/lower” and laterality, as well.
- When did it happen? The MA can help the physician establish whether this is an initial encounter for active treatment, whether the patient is in the healing stage, or if the condition is sequela.
- Where did it happen? Knowing the patient fell at home will not get us to the most specific code. We need to know where in the home, and sometimes even need to ask for the type of home.
- What was the patient status and what was the patient doing when the injury happened? If the patient has been bitten by a cat, it may be attributed to a patient status of other, but if the person bitten by the cat was a vet tech when she was holding the cat for the vet to give it an injection, the status leads to an activity for income. Assigning the code for the activity of “holding a cat” would lead to the Y code for animal care.
This example shows us that with a little bit of prodding from the MA, we can get the additional information we need for a specified code. [more]
Determining a hospital’s individual base rate or reimbursement is a complicated process best left for the hospital chief financial officer (CFO). However, a quick description may better illustrate how the IPPS works. CMS describes the following steps on its website at www.cms.hhs.gov/AcuteInpatientPPS.
Hospitals submit a bill to their Medicare fiscal intermediary (FI) for each Medicare patient they treat. The FI is a private insurance company that contracts with Medicare to carry out the operational functions of the Medicare program. Based on the information provided on the hospital’s bill, the FI categorizes each case into an MS-DRG, which determines how much payment the hospital receives.
The base payment rate is a standardized amount that is divided into a labor-related and non-labor-related share. CMS adjusts the labor-related share by the wage index applicable to the area where the hospital is located. The non-labor-related share is adjusted by a cost-of-living factor. This base payment rate is multiplied by the MS-DRG’s RW to determine reimbursement for each individual patient encounter.
If CMS recognizes the hospital as serving a disproportionate share of low-income patients, the facility would receive a percentage add-on adjustment for each case paid through the IPPS. This percentage varies depending on several factors, including the percentage of low-income patients served. CMS applies the adjustment to the MS-DRG base payment rate, plus any outlier payments received.
CMS pays an add-on amount to approved teaching hospitals for indirect medical education. This additional payment varies depending on the ratio of residents to beds under the IPPS for operating costs and according to the ratio of residents to average daily census under the IPPS for capital costs.
CMS also provides an additional payment for cases that include technologies that meet the new technology add-on payment criteria.
On occasion, CMS may consider a specific patient’s stay as an abnormal situation. Such patients consume a considerable amount of facility resources. CMS identifies these as outliers and increases payments for such situations to protect the hospital from large financial losses due to unusually expensive cases. CMS adds all outlier payments to the base payment rate to determine the final reimbursement payment for the hospitalization.
Editor’s note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.
With CDI being less than a decade old, many departments are forced to home grow their CDI specialists due to the lack of experienced CDI specialists within the market.Many CDI specialists either transition to CDI from their case management or HIM job or inherited the CDI job function within their department. Therefore, it is rare for a CDI department to have an established career ladder. And yet, as the profession continues to advance, and those original CDI staff members gain experience programs need to develop options for their employees to nurture their intellectual and professional growth.
The objective of a career ladder is to motivate existing staffto stay in the field of CDI. Many individuals seek new professional opportunities when they see no career advancement opportunities or compensation growth available at their institution. Here is an example of what a CDI career ladder might look like:
5+ years of experience in CDI
CCDS or CDIP Credential
Support effective CDI department staff activities and manage performance of CDI department and staff
Provide staff with continuing CDI education and training
Reconcile fellow CDI specialists’ entries in CDI tracking tool to assure accuracy of provider clarification, abstraction of clinical indicators, and the assignment of initial DRG and working DRG
Generate case mix index (CMI) report and CDI dashboard
Provide educational presentations to various physician groups on specific documentation improvement topics
Active participation in team meetings, physician education, and leadership meetings
CDI Specialist Level 3
3+ years of experience in CDI
CCDS or CDIP credential
Assist CDI manager with reconciliation of data
Assist CDI manager with educational presentations
Assist CDI manager with team training
Maintains productivity standards
CDI Specialist Level 2
2–4 years of experience in CDI
CCDS or CDIP credential
Maintain productivity standards
CDI Specialist Level 1
0–2 year of experience in CDI
Maintain productivity standards
Editor’s Note: This excerpt comes from the recently published book, The Complete Guide to CDI Management, by Cheryl Ericson, MS, RN, CCDS, CDIP, Stephanie Hawley, RN, BSN, ACM, and Anny Pang Yuen, RHIA, CCS, CCDS, CDIP.
At their most elemental, CDI programs ensure diagnoses and treatments described by treating physicians accurately reflect the patients’ severity of illness using officially sanctioned International Classification of Diseases 10th Revision, Clinical Modification and Procedural Coding System (ICD-10-CM/PCS) terminology, and that such codes are appropriately captured and reported by the treating facility.
Most facilities only focus on this. In fact, most facilities, persuaded by the financial benefits of capturing additional complications or comorbidities (CC) and major complications or comorbidities (MCC) on the CMI of their biggest payer—Medicare—frequently limit the scope of CDI specialists’ reviews to this regard.
The physician advisor should push the facility to expand CDI efforts beyond the scope of CC/MCC capture and fiscal return on investment not only for compliance considerations but also to help earn support from the overall medical staff. Many CDI programs have steered away from the term “improvement” in favor of the term “integrity.” Some suggest that the term “improvement” sets the hospital administration at odds with its physicians implying that physicians’ documentation needs to “improve.” Others imply that for most medical staff, the term evokes a financial connotation—that CDI is about “improving” the facility’s finances over all else.
Whether your program uses the term “improvement,” “integrity,” or some other title, the underlying concern is to address the inherent “value” of CDI efforts in improving a whole host of hospital and patient outcomes. Additionally, the physician advisor needs to assure the medical staff that there is nothing illicit in routine interrogations of the medical record to ensure accuracy. Remember that CMS states:
“We do not believe there is anything inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.”
While many CDI programs start out fiscally focused, the ultimate goal should be to help physicians craft a record that accurately reflects their patients’ illness—to make their patients appear on paper as sick as they are in person. This documentation must be in the medical record because the pendulum in U.S. healthcare is swinging, and in many case has already swung, from a quantity-driven system to a quality-driven one.
If routinely practiced, CDI efforts improve patient outcomes—simply put better documentation improves the dialogue between physicians. Sadly, most physician discussion of a patient’s care, isn’t a face-to-face—it is the information contained in the medical record that allows one physician to quickly determine what care has been provided for what diagnoses thus far and which conditions he/she needs to monitor and care for.
As an example, try to remember the worst “code blue” situation you were ever involved in during your residency training or recent practice experience. When you reviewed the chart at that critical moment, was there anything useful in it that could have helped you address that patient’s immediate needs any better? There is nothing more frustrating or unsettling than to examine the chart of an acutely decompensating patient who has been in your facility for two weeks yet there is no useful information to be found.
Editor’s Note: This excerpt came from the Physician Advisor’s Guide to Clinical Documentation Improvement.
A query should include the clinical indicators however it should not indicate the outcome of reimbursement or even quality scores. The goal is accurate and compliant documentation. With accuracy as the goal, there are times when the query will generate improved reimbursement and quality scores, and other times when they will lower reimbursement and quality scores. When communicating the reason for a query, the CDI specialist should speak to the accuracy of the record over reimbursement. Thus, CDI specialists do not want to create leading queries or queries that are not supported by the clinical elements in the health record.
Compliant queries should also include patient identifiers, ensuring that the correct patient is being considered. Queries should also include the name and contact information of the person originating the query. This provides the physician an opportunity to contact the CDI specialist to clarify the query or query process.
Here are the components of a compliant query:
- Patient name
- Admit date
- Account number
- Name and contact information of individual initiating the query
- Clinical indicators that support the query
- Statement or question of the issue
An example of a compliant query joint ACDIS/AHIMA query practice brief, Guidelines for Achieving a Compliant Query Practice, is for clarification of specificity of a diagnosis. This type of query would be appropriate for when documentation of the condition has already been provided but greater specificity is needed for accurate code assignment.
Can the etiology of the patient’s pneumonia be further specified? It is noted in the admitting history and physical examination this obtunded patient had a history of nausea and vomiting prior to admission to the hospital and is treated with clindamycin for Right lower lobe pneumonia. Based on the above, can the etiology of the pneumonia be further specified? If so, please document the type/etiology of the pneumonia in the progress notes.
Editor’s Note: This excerpt is from the CCDS Exam Study Guide, Third Edition, written by Fran Jurcak, MSN, RN, CCDS, and reviewed by Laurie L. Prescott, RN, MSN, CCDS, CDIP.
Often, the first step in becoming comfortable with the record review process comes in simply shadowing existing CDI staff members. If you are the first and only CDI specialist in your facility, reach out to the Association of Clinical Documentation Improvement Specialists via its CDI Talk network or local chapter events. Consider calling nearby facilities, asking for their CDI department manager. Many CDI specialists willingly open their doors to those just starting out. If your CDI manager is willing (or has connections of his or her own), perhaps you will be able to shadow a neighboring facility to get a better idea of how different CDI programs function as well.
Many CDI program managers ask candidates to do this during the interview process so both parties better understand the basic competencies and expectations of the job. Other program managers gradually introduce new CDI specialists to the process by shadowing experienced specialists at least once per week for a set number of hours or records per day. Other programs may require new staff members to jump into the reviews as soon as possible.
To positively influence your learning, consider first sitting alongside your CDI manager or mentor as he or she reviews a variety of common diagnoses. Where larger teams exist, consider rotating such shadowing experiences and taking note of how different individuals’ experiences and strengths affects how they conduct their reviews. Also, arrange time to shadow an experienced inpatient coder as well. You will find each person has his or her own method, and no method is necessarily better than the next.
When shadowing fellow employees during their record review process, consider asking the following questions.
- Where in the record do you start and why?
- What do you find provides you with the most information?
- What is a “must review” piece of documentation?
- Where are the hidden goldmines?
- How do you identify what is important to write down, track, etc.?
- How do you determine when a repeat review is needed?
- How do you determine if no further review is needed?
Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.
The case mix index (CMI) is a common metric used to evaluate the return on investment (ROI) from a CDI department. However, it is a very broad metric that is affected by more than just CDI efforts. In its simplest form, the CMI represents the complexity of the patient population, which, in turn, represents revenue.
Each MS-DRG has an associated relative weight (RW), the factor upon which an organization’s payment is based. CMS introduced the concept of severity within their DRG methodology beginning in 2008, when secondary diagnoses could be classified as either a CC or MCC. Therefore, the RW of an MS-DRG where an MCC is captured is significantly higher than the relative weight of an MS-DRG without a CC or MCC. This is why CMI (i.e., the average RW for a population over a period of time) is often used to measure the success of a CDI department. The assumption is a CDI specialist will increase the volume of cases where a CC or MCC is reported, resulting in reporting claims with a higher RW, ultimately resulting in a higher CMI.
Although CDI efforts can positively affect CMI, the CDI department’s success can only be accurately represented if all other variables remain constant. Since the RW also varies by type of MS-DRG (i.e., medical vs. surgical), an organization that performs a high volume of surgeries will have a higher CMI compared to an organization that doesn’t perform many surgeries. The type of surgeries performed also affects CMI. For example, organ transplants are very complex surgeries, so they are associated with a very high RW. As another example, depending on the size of the organization, if all the cardiothoracic surgeons attend a conference for a week, say, the organization’s CMI would likely drop due to the loss of those surgical claims.
Editor’s Note: This excerpt comes from the recently published book, The Complete Guide to CDI Management, by Cheryl Ericson, MS, RN, CCDS, CDIP, Stephanie Hawley, RN, BSN, ACM, and Anny Pang Yuen, RHIA, CCS, CCDS, CDIP. For additional information see these related articles:
The Balanced Budget Act of 1997 required a new payment method to adjust Medicare+Choice payments to account for variations in per-capita costs based on health status and other demographic factors. Some of those demographic factors were:
- Medicaid status
- Original reason for Medicare entitlement
So, the risk adjustment was based on the health risk of the patient. However, only 10% of Medicare+Choice payment rates were risk adjusted, and the other 90% were subject only to demographic adjustments. The Benefits Improvement and Protection Act of 2000 took this risk adjustment methodology to the next level and increased the payment ratio to:
- 30% in 2004
- 50% in 2005
- 75% in 2006
- 100% in 2007
In 2001, CMS developed a risk adjustment approach that balanced payment accuracy against the data burden for physician and outpatient hospital encounters. The result, in 2002, was the Hierarchical Condition Category (HCC) system.
The HCCs are diagnosis-code driven and include approximately 70 distinct disease groups derived from approximately 3,600 diagnosis codes which are mostly chronic but include some acute conditions, used primarily for outpatient services.
In 2003, President George W. Bush signed the Medicare Modernization Act, which created the Medicare Advantage program reliant solely on HCCs for payment. Medicare Advantage took the place of the previous Medicare+Choice program. Individuals who meet the criteria of the Medicare Advantage programs may have “special needs,” such as mental health concerns, long-term care, or end-stage renal disease (ESRD). The ranking of the diagnosis codes within the HCCs relates to the increased dollars received by the health plan to combat the increase in payment which providers of services receive for these high-cost cases within the healthcare system.
One of the goals of the Patient Protection and Affordable Care Act (ACA) signed into law by President Barack Obama in 2010 is to encourage provider efficiency. CMS defined “efficiency” as a ratio of observed-to-expected costs and outcomes for selected populations.
Essentially, the HCC is used to predict an individual beneficiary’s healthcare expenditures relative to the average beneficiary. These scores are used to adjust payments based on the health status (diagnostic data) and demographic characteristics (such as age and gender) of an enrollee. For example, if it costs 100 physicians $1,000 to treat a condition and it costs Dr. Kennedy $1,500 to treat a patient with that condition, Dr. Kennedy could be penalized when it comes time to adjust the payments based on risk assessments.
Furthermore, efficiency measurement metrics influencing reimbursement may be reported on CMS’ Physician Compare website.
Editor’s Note: This excerpt came from the Physician Advisor’s Guide to Clinical Documentation Improvement. Want to learn more about becoming an effective physician advisor? Consider attending our pre-conference session, Physician Advisor’s Role in CDI Boot Camp, at the annual ACDIS conference. Click here for more information.