By now you should be aware of CMS’s readmission initiative as part of value based purchasing (VBP). Medicare fee-for-service patients, or VA patients, who are admitted for any reason within 30 days of a discharge with a principal diagnosis of acute myocardial infarction, heart failure, or pneumonia are included in this initiative.
All Medicare reimbursement (not just for this patient cohort) is reduced up to 1% in fiscal year (FY) 2013 (goes up to 2% next year and 3% in FY 2015), depending on how effectively hospitals manage readmissions. While there are exclusions (for death, AMA, certain planned readmissions, younger patients, and patients with AMI who are discharged the same day) CMS does not differentiate between related and unrelated diagnoses, or preventable versus necessary admissions.
Each hospital’s penalty for this year has already been posted publicly and is readily available for review. You should look up your hospital’s penalty, if you haven’t already. A significant number of major institutions were penalized the maximum, 1%, but they contend that they are being penalized for serving the underserved (homeless, uninsured, etc.) who tend to cycle through the hospital rather than being managed in the community.
The first admission is called the index admission. Regardless of the number of readmissions within the 30 days following discharge, there is only one index admission and only one penalty for readmission. When the 30 days expire, the next admission is a new index admission. However, an index admission for heart failure and a readmission within 30 days for pneumonia is counted as both an index admission for heart failure and an index admission for pneumonia. In addition, same day readmissions for the same problem are incorporated into the index admission.
CMS is expected to add new measures to the readmissions initiative by FY2015, most likely COPD, CABG, PTCA, and other vascular conditions. At that point the maximum penalty will be 3%.
Let’s hope CMS stops there!
Separate from the readmissions initiative are potentially preventable readmissions. Potentially preventable readmissions are those admissions due to premature discharge, incomplete care, or inappropriate transfer, even if the readmission occurs at a different hospital than that of the index admission. CMS expects hospitals to complete care that should have been taken care of on the first admission. Quality Improvement Organizations (QIO) who review records for CMS look at readmissions to see if they may be related. Any admission within 30 days of the discharge date of the index admission is considered, but the QIO may deny the readmission regardless of time since the index admission particularly if there is a “chain” of admissions for the same problem.
APR-DRGs, a 3M™ product, are used to determine if the conditions necessitating the dual admissions are clinically related. A clinical relationship is presumed to exist if there is:
- A continuation of recurrence of the problem causing the index admission, or a closely related condition
- An acute decompensation of an acute condition that may not have been the reason for the index admission, but might reasonably have been related to care during or just after the index admission
- A medical readmission for an acute complication that might have been related to the care during the index admission
- A readmission for surgery to address a continued or recurrent problem that caused the index admission
- A readmission for surgery to correct a complication caused during the index admission
The Office of the Inspector General (OIG) also has its eye on same-day readmissions. It was identified as a target area in the 2013 OIG Work Plan. A Medicare patient’s readmission for symptoms related to or for evaluation or management of the first stay’s medical condition will result in the hospital’s only receiving one DRG payment, combining the original and subsequent stays into one claim.
As CDI specialists, we should be looking at how documentation affects readmissions. Look for documentation that:
- Supports planned readmissions
- Clearly defines the plan of care and the discharge plan
- Shows continuity of care and high quality of care for all diagnoses identified during the stay
Look at how principal diagnoses are documented and sequenced. Simple pneumonia triggers a targeted readmission measure, but aspiration pneumonia does not. See the opportunity?
Review documentation for clinical indicators that might trigger “post-hospital syndrome,” leading to early readmissions: sleep disturbances, malnutrition and delays in feeding, deconditioning, multiple changes in medication, inadequate or excessive sedation, and other stressors of hospitalization.
Talk with your case managers and your physicians when you see this evidence of potential problems. As clinical documentation specialists, get involved clinically and not only improve our numbers and public profile, but improve the care of our patients.
This week, Kris Cilona, RN, BSN, CCDS, at Mercy Medical Center in Canton, Ohio, will celebrate National Nurses Week by creating and displaying a poster about how nursing documentation affects CDI efforts.
“I want the nursing staff to understand what CDI is, what it is the CDI specialists are looking for in the charts, and how their documentation can help us to substantiate our queries,” Cilona wrote in a CDI Talk post.
Supported by the American Nurses Association (ANA), National Nurses Week takes place annually from May 6, (also known as National Nurses Day) through May 12, the birthday of Florence Nightingale, the founder of modern nursing. This year, the ANA chose the theme “Delivering Quality and Innovation in Patient Care.”
Just as ACDIS sponsors national CDI Week and encourages CDI professionals to spread the word about the CDI profession, the ANA provides a list of suggested activities from visiting politicians to conducting media outreach to hosting celebratory events within facilities.
As many CDI specialists proudly bear their RN backgrounds, ACDIS proudly solutes the efforts of all nurses—those who chose to move to an exciting new CDI career as well as those who choose to at the bedside of sick patients every day.
We encourage you to reach out to your counterparts and share their excitement and, like Cilona, tell them how much their daily work means to you and your CDI efforts.
As Cilona says, “Happy Nurses Week to everyone coders and nurses alike!”
Dear ACDIS member,
It’s time to gather nominations for the 2013 CDI Professional of the Year, to be awarded at the sixth annual ACDIS Conference in Nashville, May 21-23, 2013.
In addition to the CDI Professional of the Year, ACDIS will also award two members with the 2013 Recognition of CDI Professional Achievement awards.
These awards are based on your input. You are the ones who work side-by-side with outstanding colleagues who represent the best of the profession. You know them and understand the critical role they play in documentation excellence, accuracy and integrity of reimbursement, quality of care, and physician education. We’re looking for CDI professionals who have made a big impact in their own facility, among their local ACDIS chapter, or on the broader industry as well.
Please click this link, and download the nomination form. Fill it out and email it back to me by Friday, February 8, 2013.
We are excited to find the 2013 CDI Professional of the Year and will be even more excited to introduce that person to you in Nashville next May.
Brian Murphy, CPC
Association of Clinical Documentation Improvement Specialists (ACDIS)
781-639-1872, ext. 3216
In the fall we asked ACDIS members to explain what it takes to be an exemplary CDI specialist, to excel at not only medical record reviews, but also at incorporating the underlying purpose of CDI efforts into even seemingly mundane, everyday tasks. We heard from quite a few folks who shared some sound, sage advice and complied it in the January 2013 edition of the CDI Journal.
In fact, we received such a tremendous response that we thought we would continue publishing these “Superstar Stories” monthly throughout 2013. To share advice of your own, please shoot me an email at firstname.lastname@example.org and include “Superstar Stories” in the subject line. Please include your name, title, facility name, city and state. Please also indicate if you are a board member or chapter leader (or other affiliation you’d like me to list). We’d also love to have your photo.
Any CDI topic is welcome, including smart documentation tips, team building strategies, training and education ideas, or how to be an effective leader.
Q: Our CDI program is three years old and our administration still questions our productivity goals. Initially we set benchmarks at 90-95% coverage rate of Medicare/Managed Medicare; 20-25% query rate; 90% response rate and 80% agree rate. Since census varies, we also established goals of 10 or more new reviews per CDI specialist per eight-hour shift with re-reviews every 72-96 hours.
Are there newer/established benchmarks that programs should strive for? What is an acceptable number of reviews per day per CDI specialist? Finally, should intensive care unit (ICU) patients have a higher weight as they usually require longer reviews?
As an aside, I did review the information contained in the ACDIS CDI Roadmap and found it helpful.
A: We’re glad you took the opportunity to review the CDI Roadmap materials. The Roadmap committee and ACDIS team conducted extensive research in compiling the documents. The Phase I section of these materials includes a White Paper regarding variables affecting productivity and an example document of how one CDI department determined its productivity expectations. Here are the links to those documents:
- “Variables affecting standardization of CDI staffing and productivity”
- “Productivity and staffing example”
Remember that the total number of full-time equivalent staff members your facility hires depends on:
- Payer types reviewed
- Total discharges
- Accessibility of medical record
- Software available to the CDI staff (e.g., encoder)
- Other documentation duties and responsibilities assigned to the CDI staff
Productivity measures must be determined according to your individual CDI department. There is too much variability among CDI departments when you consider their role within an organization, their mission statement (e.g., revenue enhancement or quality improvement), and their available resources to create standardized expectations.
CDI departments frequently use metrics recommended by the consulting group which assisted with initial implementation. As a CDI department matures, however, these metrics may need revision.
For example, as a CDI professional becomes more seasoned he/she becomes more proficient with conducting reviews and issuing queries. A manager should expect staff query agreement rates and coding agreement rates to increase over time, but you would never expect those agreement rates to reach 100%. An agreement rate of such extent is suggestive of physician submission rather than support.
In response to your initial question, however, I think the goal of 80% provider agreement rate could be pushed to 85% due to the maturity of your CDI department. It is reasonable to expect the provider agreement rate to increase as both the CDI department and the CDI staff gain experience and develop relationships with the medical staff. It is often helpful to measure physician agreement rates as both a departmental metric and for each individual CDI specialist.
I typically don’t recommend a metric for the volume of queries expected as this can lead to a focus on the quantity of queries rather than the quality of the query. Additionally, there is variability within medical specialties as some, like cardiology, have more query opportunities than others, such as orthopedics.
The types of queries should increase in sophistication as a CDI department/CDI specialist matures. Queries should shift from simply asking for increased specificity (i.e., obtaining clarification congestive heart failure specificity as systolic or diastolic) to being able to identify vague and missing diagnoses that otherwise, would not be coded (i.e., recognizing clinical indicators of shock). These types of queries are often more complex to develop and require provider agreement/support so they may result in fewer queries and a lower volume of reviews.
I encourage CDI managers to review the types of queries being asked by the CDI staff to ensure growth of the CDI specialists in their roles. Query reviews and analysis should not simply ensure individuals comply with query guidelines. In order for a CDI department to remain viable, the CDI specialists need to educate the medical staff regarding documentation opportunities that accurately represent the complexity of the patient’s condition with terms that can be adequately captured by coding. The goal is for the coded record to precisely reflect the provider’s intent and the use of hospital resources.
The volume of follow-up reviews would be greater in a CDI department focused on quality metrics (SOI/ROM) compared to those focused on reimbursement (CC/MCC capture). A focus only on CC/MCC capture limits the number of reviews because once those conditions are captured (thereby, “maximizing” the reimbursement) no additional reviews are required as the record is complete, allowing the CDI specialist time to review other records.
On the question of record reviews for ICU patients taking longer than other reviews, again I’m afraid the answer is “it depends.” If the CDI department’s focus is reimbursement, these cases are typically maximized within the first two reviews so additional reviews are not necessary. If the focus is quality, I can see where these records can be cumbersome and require additional time and CDI staff focus.
In my previous career as a CDI manager, I did not measure staff members by volume of reviews. I believe the value of CDI efforts comes from their relationships with the providers. The value of CDI is not the number of records they review and “pre-code,” but rather in CDI specialists’ ability to change the documentation behavior of the medical staff. In my opinion, that is best accomplished by interacting with the providers—a more time consuming endeavor than simply reviewing a record. If you change the behavior of one provider, you have improved the quality of many future records. Conversely, a single query typically allows CDI professionals to improve one record at a time.
Remember coders have always queried physicians, the concurrent nature of CDI efforts provides real-time feedback to providers. That is the value of CDI efforts within a healthcare system. This is where the success of CDI efforts lay.
I know this may be a tough sale to administration who like to measure productivity, but the measurement of outcomes rather than the process (e.g., the number of records reviewed) may be a more successful approach and result in higher staff satisfaction.
Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question. Contact her at email@example.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.
What do you do when a CDI specialist arrives at one MS-DRG and the coder arrives at another? The answer is far from simple and depends on the circumstances at your particular facility, says ACDIS Director Brian Murphy.
“Most often the coder, due to his/her experience and training in coding guidelines and access to coding resources such as an encoder or other programs, is responsible for final DRG assignment,” Murphy says.
Many organizations support the coders’ right to make the final decision, says Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., in Danvers, Mass. In fact, coders may even be held liable for coding inappropriately should such errors be discovered as a pattern established to gain unearned compensation for a facility.
In a 2005 Federal Register notice the Office of the Inspector General (OIG) set forth its “Supplemental Compliance Program for Hospitals.” Although the document contains information primarily pertinent to hospital compliance officers, CDI specialists should review it to gain perspective on the variety of coding and billing missteps being targeted by government agencies, Ericson says.
Typically, CDI specialists come from the nursing world. (For evidence see the July 2012 CDI Salary Survey, which states that 72% are RNs.) They look for clinical indicators of diagnoses not currently in the medical record. Conversely, coders must look in the medical record for existing documentation and assign a code based solely on that documentation. The query process, employed by both CDI and coding staff, aims to ask questions of the physicians when the documentation is unclear, ambiguous, conflicting, poorly written, or just plain confusing.
In the past year, we have heard some discussion about the viability of concurrent coding by CDI specialists. Opinions differ about the effectiveness of this model. In the January 2013 edition of the CDI Journal, sources discuss their experiences with concurrent coding efforts. They suggest success depends on the development of clear policies and processes, effective hiring of competent, experienced professionals (including coders) to the team, and appropriate access to electronic tools and systems such as the aforementioned encoders and electronic query systems.
To prioritize their efforts CDI specialists learn the process of how to examine the record and assign what’s known as a “working DRG”—an MS-DRG that may change during the course of the patient’s stay as diagnoses are determined and care provided. Determining how the CDI team’s efforts meet and mesh with those of their coding counterparts should be part of a joint (perhaps even steering committee-level) decision at the time of CDI program implementation.
The Physician Query Handbook, Chapter 3, “Query Process Infrastructure,” includes a section on what to do with DRG mismatches. It states:
“…[cases where] the CDI specialists’ final DRG does not match the final coded DRG, [DRG mismatches] may occur for a variety of reasons… Regardless of the reason the reconciliation of these DRG mismatches represents a great learning opportunity for all involved if proactively addressed. A robust conversation of the discrepancies can lead a CDI specialist to a deeper understanding of the coding rules and regulations and [may] help coders better understand the clinical thinking of the CDI [nursing] staff. Used as a learning tool, discussion of DRG mismatches also represents a good way to foster mutual respect and understanding of the various teams’ knowledge base and job responsibilities.” (p. 59.)
The section goes on to advocate that CDI programs establish policies and procedures for how to handle DRG reconciliation as part of the CDI program creation (view a sample policy in the Forms & Tools Library). These policies may simply require the coder and CDI specialist review the record together to discuss the discrepancy, they may give the final word to the coder, or they may indicate that cases where DRG mismatches occur should be passed on to the coding manager or physician advisor for final review and input. Regardless of how your CDI program decides to handle the concern, addressing the matter upfront and putting it in a clear policy may help to resolve future interdepartmental conflicts.
by Melinda Tully, MSN, CCDS
For providers, the days of earning full Medicare payment by simply submitting complete and accurate information are drawing to a close. In 2013, Medicare will begin paying healthcare providers and facilities based on the quality of care provided, not just the quantity of services.
Then, starting in 2014, base payments will depend on the outcomes of the care documented.
So how do we shape up before we face even bigger federal cuts? Simple. Clinical Documentation Improvement. CDI. It’s an acronym that everyone in the healthcare industry should become familiar with.
I sometimes like to think of CDI as investigative reporting for healthcare. CDI helps make sure the patient record is telling the true clinical patient story, including what care the physician provided and why, to ensure the record is coded and billed appropriately. For healthcare facilities and physician practices to thrive through these changes they need to understand the value of CDI and its direct impact on both patients and physicians.
Patients a Priority
Regardless of the rule or regulation, physicians will not change what they do until they see what’s in it for patients. While it’s easy to see how better clinical documentation can help patients, it’s hard to make that a reality in a typical healthcare setting where clinicians are juggling tight schedules and hectic patient workloads.
The most successful CDI programs work with clinicians to enhance the core training they learned in medical school, teaching them how to document a patient’s true clinical story during their workflow to best represent the complexity of a patient’s case and decisions made along the way. This helps keep patients safe, improves communication between clinicians and protects providers from lost revenue.
Quality scores are becoming more transparent to the public every day and high mortality rates and medical errors make headlines. While many CDI programs are led by finance departments, clinical documentation is not an issue reserved for HIM departments. Clinical leaders from many areas including chief medical officers and quality officers need to be involved in CDI to keep the patient’s best interests in mind.
For the last several years I have worked with physician leaders at a large academic medical center to identify and implement CDI efforts focused on improving quality. These efforts have transformed the organization’s performance metrics, improving mortality indexes so they more accurately reflect the severity of illness of their patient population. These quality indicators are important because decisions are made based on these types of quality metrics – whether it’s by patients seeking treatments or payers evaluating providers. The best part about this customer’s success is they have improved their documentation and now their clinical information is so good that when physicians look ahead to pay-for- performance, Accountable Care Organization implementation and bundled payments, they know they are in good shape for the future. [more]
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.
Do you take advantage of your ACDIS membership benefits? If I asked you to list the benefits of your membership I bet there’s one you’d miss. It’s the job posting board on the ACDIS website. As a member, you are entitled to post up to four job openings per year.
I know, I know you’re ridiculously happy at your job and wouldn’t dream of leaving for another opportunity, right? But surely your program is thriving and growing and you need more talent on your staff, right? Advertise at no cost on the ACDIS job board. You’ll reach the right group candidates for your opening, people who know the industry and more importantly, know what it takes to get the job done. Each posting includes a job description and many include information on benefits and compensation.
Here’s a quick recap of recent postings:
- Athens, Ga., DRG Program CDI specialist
- Chicago, Ill., Associate Director, CDI specialist
- Philadelphia, Manager, compliance audit and education
- Akron, Ohio, DRG CDI specialist
- Lansing, Mich., CDI Manager
- Boston, Mass., RN CDI specialist
- Phoenix., Ariz., RN CDI specialist
- Brooklyn, N.Y., Director Coding and Coding Compliance
- Scranton, Penn., Manager, Inpatient Coding and DNFB
In addition to these facility-specific posting, we often get posting for remote openings, such as these:
- Nationwide CDI specialists
- Various nationwide Senior consultants in CDI
- Atlanta and SE region Medicare DRG auditors, remote/virtual coders
Click this link to check out what’s on the board today. And check back often!
I’m soliciting tips and advice from the ACDIS community to help celebrate the Association’s 5th anniversary. We will compile this advice in a “Things You Need to Know to be a CDI Super Star” white paper. (That’s a placeholder title. I’ll keep all contributors in the loop regarding the final format, title, and number of submissions.)
Please note that by responding, you are giving ACDIS approval to use your advice, and attribute it to you. Please include your name, title, facility name, city and state. Please also indicate if you are a board member or chapter leader (or other affiliation you’d like me to list). We’d also love to have your photo.
Any CDI topic is welcome, including smart documentation tips, team building strategies, training and education ideas, or how to be an effective leader. However, I do ask that you try and limit your tip/advice to roughly 500 words. The deadline is Friday, November 9.
Email your submission to Penny Richards. Please use “CDI Tip” as the subject line.
I can’t wait to read what you send me!