Recently a question was posed in ACDIS CDI Talk about establishing CDI/coder DRG match rates. (Read the related Blog post.) Shameless plug here; if you do not visit CDI Talk, you’re not taking full advantage of your ACDIS membership. It’s the best national networking opportunity you’ll have outside the annual conference.
Anyway, being the shrinking violet I am, I jumped right in with my two cents (before taxes):
“I do not have a CDI/coder DRG match metric in my program. While I do expect the CDI specialists to understand MS-DRG and produce a working DRG, and I believe fervently in the importance of reconciling the DRG so that the most accurate codes are reported, I don’t actually care if the working DRG matches the final DRG. I do care that the CDI specialist understands how the DRG is impacted by the documentation and how changes in the documentation may impact the DRG. I do care that the CDI specialist and the coder come to an agreement that the final billed DRG is the correct representation of the documentation. But for me, evaluating a CDI specialist on his or her ability to see into the future leads to a lot of wasted effort on the coding process that should be spent on the documentation process, and generates a lot of competition between coding and CDI that should never exist in a collaborative environment.”
When I was a CDI specialist, the match rate stressed me most. I’m not a coder. Our differences make us both uniquely awesome and a great complement to each other. My CDI team includes both RNs and coders and that’s the way I like it. Most CDI specialists are nurses and will never be coders. And even though some CDI specialists are coders, that’s no longer their role.
The role of the CDI specialist is to identify and correct existing documentation issues and to prevent future documentation issues. It’s not to code the record. As a CDI specialist, I assigned many, many codes, and calculated many, many working DRGs. For me, this served to clarify how the documentation would impact the coding, and how a query would impact the coding, so I thought the process was important. In the end, though, the DRG I assigned was irrelevant; the final DRG was the coding specialist’s determination.
We didn’t always match. Sometimes documentation would come in after my final review that affected the DRG. Sometimes it was a matter of picking between two diagnoses that both met the definition of principal diagnosis; I picked one, they picked the other. Sometimes I just saw things differently than the coding specialist did.
Sometimes I accepted the coding assignment as a valid alternative to mine. Sometimes I would disagree with coding’s determination, and then began the process of reconciling the difference.
Sometimes they agreed with me, sometimes they didn’t. The reality is that it was their name, not mine, going on the coded record, and they would have to stand behind their coding assignment, so they always had the last word.
Q: What should I do if I see a non-compliant query in the chart? Should I remove it, let my co-worker know, or just leave it in the chart?
A: Addressing non-compliant queries can be tricky. The best course of action would be to share your concerns with your supervisor who can then either confirm your perception of the query being non-complaint or could let you know why he or she feels the query is acceptable. Ask your manager or supervisor to go over any internal query policies to help you better understand your facility’s compliance parameters.
Most facilities have standard query policies and procedures which reflect national standards (such as the 2013 AHIMA/ACDIS “Guidelines for Achieving a Compliant Query Practice” brief). They also have processes in place to help co-workers handle questionable query processes.
If there are no policies and procedures in place (or if you and your coworker are only the two CDI staff querying physicians at your facility) you may want to review the latest query practice information together and approach whatever management team is in place to develop such policies yourselves.
If the query is truly non-compliant, I would definitely want the supervisor to address it rather than you doing so on your own. It may be that the individual needs additional training or it may become a potential performance issue. In which case your manager or supervisor needs to know about the situation and may even need to have a documented conversation with the CDI team member who left the query.
You wouldn’t want to remove the query. The physician may have already reviewed it and responded in his or her progress note. If auditors or internal staff later question where that diagnosis came from, no query trail would exist and you may not be privy to those subsequent questions. If the supervisor or program manager determines the query was indeed non-compliant he or she may need to also circle back to discuss the situation with the physician and/or coding team.
When Jennifer Love, RN, BA, CCDS, accepted a CDI position Kindred Healthcare, one of the nation’s largest long-term acute care (LTAC) providers, she found a brandnew opportunity. As its name implies, LTACs provide care for patients with serious (acute) medical needs over a long period of time, usually between 20 and 30 days. Most CDI specialists work in short-term acute care (STAC) facilities. So Love saw the LTAC opening as a chance to broaden her CDI horizons.
“It is exciting to see CDI expand out like this,” she says. “I feel like I dove into the future.”
The payment system is essentially the same as that of STAC facilities—LTACs use ICD-9 codes and MS-DRGs for Medicare patients, for example. But whereas STACs look to reduce a patient’s geometric length of stay (GLOS), an LTAC patient is expected to require a longer treatment period.
LTACs treat a very specific type of patient, says Love. Patients can be morbidly obese, suffer from bed sores and acute renal failure, and have often undergone tracheostomies.
The top DRGs at Love’s facilities include:
- 207: respiratory system diagnosis with ventilator support 96+ hours
- 189: pulmonary edema and respiratory failure
- 592 and 593: skin ulcers with CC/MCC
- 870 and 871: septicemia or severe sepsis with mechanical ventilation 96+ hours; and with MCC
If a patient leaves the LTAC sooner (or longer) than expected, a number of questions need to be asked and answered, says Becky Slagell, BA, MHA, RHIT, CPHQ, regional senior director of case management for the Central Region Long-Term Acute Hospital Division at Kindred Healthcare.
“We need to ask ourselves why that patient was discharged earlier than patients with similar concerns. Was [he/ she] truly safe for discharge? Was [he/she] able to go home earlier than normally expected for that type of patient? Did [he/she] transfer back to a STAC? If so, why?” Slagell says.
“There shouldn’t be a high rate of COPD in a LTAC setting,” Slagell says. “That is a chronic condition that by itself does not require our level of care. When a CDI specialist sees that, they’ll look further in the record and see what the situation is. Is there an acute exacerbation of the COPD such as aspiration pneumonia or respiratory failure?”
This complicated level of care makes the role of the CDI specialist very important for this particular setting, says Slagell.
Complex metrics regarding physician response rates and staff productivity help the CDI manager quantify the CDI program benefits to facility administrators and to CDI program staff when presented properly. The manager helps communicate facility priorities to his or her team and to illustrate the needs of the CDI department to hospital administrators. Furthermore, the manager must maintain awareness of any changes in government regulations and industry guidance. Changes in the larger industry will affect the CDI team’s productivity, and any metric must be discussed within the context of these changes.
The manager should review not only the percentage of charts examined by the team, but also the number and type of queries needed each month. It is important to document the outcomes of these reviews. The aggregate data can then be used for process improvement and to support corporate compliance activities. The following is a list of items to review routinely and share with the compliance committee and administration when relevant.
- Trends in types of queries: one condition being queried routinely (e.g., a type/phase of congestive heart failure [CHF])
- Trends by physicians: multiple queries to the same physician regarding the same condition (e.g., a physician continuing to use the term urosepsis after repeated queries and communication as to the need for further specificity)
- Trends by individual CDI specialists (e.g., a CDI specialist continuously querying for specification that is already documented in the chart)
A change in ICD-9-CM Official Guidelines for Coding and Reporting may affect the query percentage for a period of time. A good example is the increased documentation specificity required for heart failure when coding guidelines were revised and reindexed to allow for greater specificity in reporting the phase and specific type of heart disease. Prior to the implementation of MS-DRG, it was only necessary for the physician to document “heart failure” or “CHF.” Both terms were considered CCs.
If one looks back far enough, many CDI teams’ data show a surge in queries for the period of time immediately prior to and following the implementation of the MS-DRG system.
In summary, team performance cannot be determined solely through measurement of query volume. Many factors influence this indicator and it should not be used to determine a program’s effectiveness, but rather should be used as an indicator of opportunities for improvement (e.g., physician education, form revision) or performance improvement over time.
When ACDIS put out the call for participation in its 2014 CDI Salary Survey last week more than 500 people responded. We need you to take a few minutes to complete the survey, too. Why? Because these surveys provide us with a snapshot view of how changes in the profession affect how you get paid for the work you do. And, you can use the results to make the case for changes in your own compensation! It’s true. We’ve heard from a number of ACDIS members who’ve analyzed the data against their own circumstances and got the compensation they deserved.
Last year about 25% of respondents said they earned $60,000–$69,999 annually; but the number of individuals earning $50,000-$59,999 decreased by 4% and the number of those earning $70,000-$79,999 increased by about 4%.
How have salary rates changes since last year’s survey? You tell us! Please complete the 2014 CDI Specialist’s Salary Benchmarking Survey. We will share the results in a special report later this year.
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. Consider higher staff ratios for programs that expect CDI specialists to perform multiple functions (core measures review, utilization management, etc.) and a lower ratio for programs that perform condition clarifications only. Other considerations include the amount of vacation time staff have available; programs that hired 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 or if they are required to re-review the case periodically until discharge. This can also have an impact on the number of cases per CDI staff member.
Keep in mind that the CDI staff generally work Monday through Friday so their actual daily census will be higher, especially on Mondays. Increasingly, however, facilities appear willing to adopt a more flexible schedule. These schedules may include a rotating day of the weekend and/or different staggered shifts to make CDI specialists more available to the medical staff.