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Weekend Reading: Six steps to hospital reimbursement calculations

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

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

Step 1

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.

Step 2

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.

Step 3

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.

Step 4

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.

Step 5

CMS also provides an additional payment for cases that include technologies that meet the new technology add-on payment criteria.

Step 6

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.

Weekend Reading: Example of a CDI career ladder

Want to climb the CDI career ladder? Two ACDIS speakers will tell explain how during today's presentations.

Want to climb the CDI career ladder?

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:

CDI manager 

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.

Sunday Reading: Start physician education with quality improvement

Trey La Charite, MD, at left, ACDIS Director Brian Murphy, center, and James S. Kennedy, MD, CCS, CDIP, play up the Tennessee state-theme during the 2013 ACDIS conference.

Trey La Charite, MD, at left, ACDIS Director Brian Murphy, center, and James S. Kennedy, MD, CCS, CDIP, play up the Tennessee state-theme during the 2013 ACDIS conference.

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. 

Weekend Reading: Components of a compliant query

CCDS Exam Study Guide

CCDS Exam Study Guide

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.

Weekend Reading: Shadowing staff

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

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.

Discussion Point

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.


Weekend Reading: The case mix index

Everyone is catching up on their weekend CDI reading!

Everyone is catching up on their weekend CDI reading!

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:

Weekend Reading: Hierarchical condition classifications

The Physician Advisor's Guide to CDI.

The Physician Advisor’s Guide to CDI.

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:

  • Age
  • Sex
  • Medicaid status
  • Disability
  • 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.

Weekend Reading: Measuring individual productivity


The Complete Guide to CDI Management

A CDI manager must be able to perform further analysis to measure individual productivity and review quality. This type of performance drill down allow continuous feedback and educational opportunities for both new and experienced CDI specialists.

Since every hospital’s CDI department may have a different set of core responsibilities, the key performance indicators (KPIs) may vary. Frequently, new CDI departments focus on clarifying the principal diagnosis and any secondary diagnoses that may qualify as a CC/MCC. The capture of these often leads to a change in MS-DRG assignment, which in turn potentially increases the patient’s hospital expected length of stay (LOS), severity of illness (SOI), and risk of mortality (ROM).

As the department matures and grows, a CDI specialist’s review of the record may begin to have a broader focus, with the goal of ensuring the accuracy of the entire medical record for other aims. These might include quality metrics, patient safety indicators (PSI), and queries that impact other hospital reporting (e.g., mortality risk adjustment models). That said, a CDI specialist’s effectiveness is not measured only by the number of cases reviewed but also by standards established by the CDI manager.

Other measurements that may be considered include:

  • Query rate
  • Provider response rate
  • Quality of reviews being performed

Daily CDI productivity is frequently associated and measured by the following, but is not limited to:

  • Total number of charts reviewed (initial reviews versus subsequent reviews)
  • Total number of queries (verbal versus written)
  • Provider response rates

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.

Weekend Reading: An effective physician advisor

Physician Advisor’s Guide to CDI

Physician Advisor’s Guide to CDI

To be effective, physician advisors need to have:

  • Credibility with the medical staff: They should be known to their medical staff associates, be fairly well respected, and be able to work well with others
  • Leadership experience: Frequently meeting the above objective means this individual has already played a leadership role within the hospital or medical staff, although not necessarily so. One may have great credibility among one’s peers without having been in a leadership position. However, those who have served in previous leadership roles come to the CDI physician advisor position with an awareness of potential aspects of the job, such as interdepartmental relationships, meeting requirements, reporting and analysis responsibilities, among other items.
  • Active clinical practice: Those physician advisors who opt to maintain their clinical practice may be an asset to the CDI team. In dealing with day-to-day patient care concerns, these individuals have real-life clinical experiences to draw from and share with their CDI and medical staff teammates. They can argue in support of the CDI mission without being negatively labeled as an arm of the hospital administration on one side and on the other and can support the medical staff when CDI requests or processes become too onerous or burdensome.
  • Credibility with hospital administration: Those with previous leadership experience may well have credibility with the hospital administration, but this is not a foregone assumption, either. What CDI physician advisors needs to have is an awareness of the overall goals of the institution and how the different departments serve not only their individual specific goals but also each other and the overall mission of patient care. An effective physician advisor will understand the importance of effective communication with the hospital administration while being flexible to its changing needs.
  • Generic insight about clinical documentation and regulatory oversight: Clearly, a physician advisor who is already well versed in the nuances of healthcare regulations would be a boon to any CDI program. While that is rarely the case, strange mythical creatures do exist (look no further than the authors of this book), so you should snap them up if at all possible. That said, even those without explicit knowledge of healthcare and coding guidelines should be aware of the role such regulations play on both the business of healthcare and on the delivery of the care itself. Such individuals must be interested in pulling at the threads of why such rules exist and how to best adapt to them rather than be confused, frustrated, or overwhelmed by them.

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.


Weekend Reading: Physician judgment

The Physician Queries Handbook

The Physician Queries Handbook

CDI program leaders should work with physicians to outline clinical indicators and definitions for “controversial” diagnoses. CDI programs must ensure that any such information is part of ongoing CDI and physician education and that it gets updated annually or at least as frequently as advances in regulations or healthcare standards demand. While such efforts provide guidance to all parties, physicians can still determine a diagnosis based on his or her clinical judgment.

For example, when a patient presents with pneumonia, one of the clinical indicators would be an infiltrate on the chest x-ray. However, if the patient is severely dehydrated, the x-ray may not show an infiltrate. Similarly, if the patient presents with an acute exacerbation of congestive heart failure in addition to pneumonia, infiltrates may not be visible. In both of these examples, the physician can use his clinical judgment and assign a pneumonia diagnosis and treat accordingly.

Unfortunately, there are no exact answers when determining how much clinical evidence to include in a query. Find the “sweet spot” wherein there is enough evidence to support a given diagnosis without overwhelming the reader

Clinical evidence should generally include information from some or all of the following areas:

  • Signs and symptoms with duration
  • Diagnostic test results
  • Lab findings
  • Findings of consultants
  • Treatment performed

For example, when writing a query for pneumonia the following information should be included:

  • Signs and symptoms: fever 101°, green sputum, cough for more than a week
  • Diagnostic test results: chest x-ray with left lower lobe infiltrate
  • Lab findings: white blood cell count of 14,000
  • Treatment: started on Levaquin intravenous (IV) piggyback (short-term infusion)

Notice this example did not include multiple sets of vital signs, as the diagnosis of pneumonia is primarily made based on signs and symptoms and radiological findings. Alternately, some diagnoses are less straightforward and require more clinical evidence to write a compliant query.

For example, when writing a query for a suspected case of acute renal failure, more in-depth information may be needed with the treatment and outcome tied together, such as:

  • Signs and symptoms: Severe nausea and vomiting for one week and unable to keep down fluids. History of normal creatinine values prior to admission
  • Lab findings: Creatinine 3.6 at admission and decreased to 1.2 after 24 hours of IV fluid boluses
  • Findings of consultants: The nephrologist states “renal failure”

Those new to the CDI profession often struggle to determine the amount and type of clinical evidence to include with a query. Coding Clinic for ICD-9-CM goes on to say that such facility-specific policies can help provide instruction as to “when they should query physicians for clarification.”

Editor’s Note: This excerpt was taken from Marion Kruse, MBA, RN.