In 2008, only 11% of poll respondents indicated their CDI program either reviewed outpatient records for documentation improvement opportunities or were looking to expand into outpatient (8% and 3% respectively) areas. How has the climate changed?
According to more than 400 respondents to the question this past month on the ACDIS website poll, 35% now say they conduct outpatient reviews and 61% do not (1% say they only review emergency department records, and 2% plan to start outpatient reviews within the next year).
With the advent of Medicare Administrative Contractors (MAC), which review both Part A (hospital) and Part B (physician) billing, payers are now looking to ensure that physician and facility billing match, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDIS, CCDS, an ACDIS Advisory Board member and independent consultant based in Madison, Wisc., in a previous edition of the CDI Journal. This combined review could mean new vulnerabilities for hospital and physician reimbursement, but it also represents a new opportunity for CDI specialists.
“We [as CDI specialists] are trying to get buy-in, support, from physicians,” Krauss says. “But we don’t explain how documentation affects their business. Outpatient documentation review is a good segue for helping physicians understand the importance of documentation in the medical record.”
Although the majority of those participating in the recent ACDIS poll remain focused on inpatient record reviews the trend has shifted from that illustrated in the 2008 poll. As more government initiatives roll out, no doubt CDI will continue to advance into the outpatient arena. If you are currently conducting such reviews, please share with us your story in the comment section below.
Editor’s Note: This article first appeared in the bi-monthly email newsletter CDI Strategies.
Of the nearly 450 respondents to a recent ACDIS website poll, 50% say they conduct pre-payment record reviews, with an additional 7% indicating their facility is considering implementing such reviews in 2014. Of that 50%, 35% of CDI departments conduct such reviews themselves.
Ever wonder how many records your CDI counterparts at the hospital down the street have to review? Has your CDI specialists’ list of duties expanded exponentially over the years but the productivity expectations remain the same?
Please take a few minutes to participate in this CDI program structure and productivity survey. In it, we ask questions regarding your CDI program’s reporting structure, the number of record reviews you perform, and whether your facility plans to hire new CDI staff in response to ICD-10.
Your responses will illustrate program structure and productivity trends across the country. We hope the results will help you draw meaningful comparisons with other CDI programs and build a case for hiring additional staff. To participate in the survey, click here.
There are only so many hours in a day. And only so many minutes to explain the complicated process of coding and reimbursement to a less than eager room full of physicians. In an hour-long session, Bryan P. Hull, MD, site lead for ICD-10 enterprise project and assistant professor of medicine at Mayo Clinic Hospital in Phoenix found he spent 30 minutes or more talking about the definition and purpose of the DRG system—over and over again.
“I knew there had to be a better way to do this,” says Hull.
Hull began researching online tools for video creation and came upon VideoScribe which essentially animates PowerPoint presentations making it seem as though someone has been videotaped hand drawing the presentation.
With a solution in hand, he just needed a story-line for his presentation and support from his CDI teammates, which he readily received.
“Some people stay up late at night thinking about the meaning of life,” Hull states at the outset of the five minute video, as an artist’s hand quickly sketches a cartoon image of a Greek philosopher. “Other people think about the possibility of life on other planets,” he adds as the artist colors an alien head in a thought bubble. “But in care management, other things keep us up at night; things like clinical documentation improvement.”
The video goes on to describe the role of documentation in quality reporting and the role of the CDI specialist in helping physicians capture that documentation. Hull provides two case examples of patients with pneumonia and walks through the different conditions, demonstrating how variables such as home oxygen, COPD, and other conditions affect the patient’s severity of illness, length of stay, and the DRG assignment.
Now, Hull goes to the meetings, runs the video, and makes himself available to support the CDI team members. “We start the video and the physicians recognize my voice and laugh,” he says. “They really get a chuckle out of it. It opens the door to the CDI team to take over the presentation and drill down into more detailed documentation improvement initiatives.”
Mayo has played the video at all its Phoenix divisions and even at the enterprise-wide CDI conference held in the fall. Now, Hull envisions adding other videos focusing on DRGs 177, 178, 179, and turning them into a collection.
“We’ve gotten a lot of feedback from the providers regarding the videos. We can measure the difference, the improvement in the documentation overall. While that may not be due specifically to the video we know that our training matters.”
I’m sure most of you are familiar with the holiday favorite “On the first day of Christmas.” The song, written in the 18th Century, recounts the delivery of increasingly fabulous gifts beginning on Christmas day and continuing through to the feast of the Epiphany, or “Twelfth Night.”
The original lyrics (which included something about five gold rings and geese a-laying) have been reworked to both entertaining and memorable results over the decades. In 2008, Bonnie Epps and Jamie Doster of Emory HealthCare in Atlanta, adopted the song for CDI professionals.
It went: “On the first day of Christmas my CDI manager gave to me. . . one CDI program. One the second day Christmas my CDI manager gave to me. . . two POA’s. . . and one CDI program. . .”
You get the gist. The rest of the countdown included:
3 – Doc MS pain
4 – E-mails from the boss
5 – Educational CD’s
6 – CCs
8 – Re-reviews
9 – DRG’s wrong
10 – Reason codes
11 – Queries answered
12- ADT feeds
Today, five years later, we may very well have some new lyrics to add to the song. How about “On the first day of Christmas my CDI manager gave to me:
- CDI program
- Reviews for patient safety indicators
- Claims denials
- Medical necessity reviews
- DRG mismatches
- New CDI staff members to train
- Educational presentations to deliver to physicians
- EHR implementation meetings
- Outstanding queries
- Coding articles to read
- Secondary diagnoses to review
- ICD-10-CM/PCS educational sessions to attend
What would you add to this list? Post your suggestions below! Merry Christmas!
Establishing a CDI program doesn’t guarantee compliant documentation and/or coding. Queries that focus on obtaining ‘buzz’ words that add reimbursement but don’t add anything to clinical care overlook two important factors that relate to overall revenue integrity:
- Clinical context
- Quality of clinical documentation
Both of these factors are essential for decreasing the financial risks associated with Recovery Auditor, Medicare carrier, Fiscal Intermediary, and Medicare Administrative Contractor (MAC) post-payment and pre-payment reviews and recoupments. As stated in the most recent Recovery Audit Program Final Scope of Work, Recovery Auditors are required to employ registered nurses and clinicians who must review medical records for medical necessity and clinical validation.
Diagnostic conclusion statements previously carried sufficient weight for coders to confidently assign an ICD-9-CM diagnosis code that would withstand the test of time in the event of an outside review. However, these statements are insufficient as a matter of clinical documentation integrity when they don’t incorporate a clinical context for understanding. The clinical context of the documentation plays an integral role in establishing medical necessity for the hospital admission as well as the patient’s continued stay.
The following case study represents best practice for appropriate and proper documentation in support of the clinical context and medical necessity for admission.
Chief complaint: Chest pain, headache, cough, and fever unabating
HPI: The patient is a 35-year-old female who initially came to the ED two days prior with complaints of a severe, bothersome, ongoing cough for one week, productive of thick yellow sputum. She has also had a fever for three days as well as worsening shortness of breath present mainly on exertion. She also had chest pain in the substernal area that has been continuous and worsening for the past four days, but increased with coughing. She has had headaches for approximately three days and primarily when coughing. She has had decreased p.o. intake for two days. In the ED, she was given IV Rocpehin x 1 and sent home with a prescription for Biaxin™. The patient stated that she did fill the prescription but that she was taking Motrin® and Tylenol® for the pain. She stated that neither medication helped her and that her temperature went up to 103°. Thus, she came back to the ED. In the ED, a chest x-ray was repeated today. The x-ray continues to show left lower lobe infiltrate that worsens with increased haziness and more of a white out picture. Her white count was 15,000 with 12 bands, 18 neutrophils. As a result, it was determined that the patient had failed outpatient treatment and required inpatient hospital admission.
Impression and plan: Pneumonia with sepsis. The patient is being admitted because she meets the severe sepsis criteria with temperature of 103°, tachycardia with heart rate of 140, infection of pneumonia, and white blood cell count 15,000 and neutrophils 18. She has also failed reasonable outpatient management. She is being placed on IV Rocpehin and IV Zithromax®. Blood cultures have been sent. She will get Duoneb® and be placed on pneumonia protocol.
Clearly, the clinical documentation in the above case study accurately and effectively captures the patient’s true severity of illness and the physician’s clinical judgment, thought processes, and clinical rationale for admission.
In its FY 2014 IPPS final rule, CMS states that there will be a presumed inpatient status when a patient remains hospitalized for two midnights. Effectiveness of clinical documentation in support of the physician’s decision to admit as an inpatient assumes even more importance in light of this change.
Auditors will be looking for a clear outline of the physician’s clinical rationalization and reasonable expectation of a hospital stay that spans two midnights. Diagnostic conclusion statements will no longer sufficiently capture the clinical context and medical necessity for inpatient admission.
The most effective approach to CDI involves synergy between coders and CDI specialists. The query process can—and must—expand beyond the traditional realms to incorporate clinical context and medical necessity. This will take a collaborative approach involving the CDI and the coding staff.
CDI specialists are on the front line, and they have the opportunity to reach out to physicians and provide one-on-one education about:
- Perils of the EHR
- Cutting and pasting documentation
- Need for succinct documentation of the HPI
- Need for progress notes that provide an accurate account of a patient’s progress while he or she is hospitalized
Coders review the record at its completion, essentially acting as an outside reviewer.
Quality documentation is an essential part of the revenue cycle process. When considering the quality of your documentation, ask yourself the following question: What purpose do CDI specialists and coders serve if the hospital fails to be reimbursed for the excellent clinical care provided? Your answer will be the impetus to expand the thrust and focus of CDI.
As some of you may know, ACDIS is working on a CDI staff training manual. The book (due to publish prior to the 2014 conference) will help program managers train their new staff on CDI basics.
But what should those individuals who are thinking about making the leap from either the nursing world or the coding world into CDI do to get themselves up to speed on CDI practices prior to even applying for a CDI position?
It is a good question—one put to us recently by someone in just that position. Her facility did not have a CDI program as of yet, but she felt as though it may soon create one and she wanted to be ready to apply for a position if one became available.
I first congratulated her on being so in tuned to her facility needs, on being an ACDIS member, and for asking the question. We chatted a bit and came up with a few possible tips for others out there who are hearing the rumblings on the wind about the importance of CDI in the new ICD-10 environment and are considering a career change.
It may seem obvious but experienced, credentialed clinical documentation improvement professionals are highly sought after, well compensated, individuals. According to ACDIS’ 2013 Salary Survey, 158 CDI specialist respondents hold the certified clinical documentation specialist certification and of those, 41% earned more than $80,000 annually. As more hospitals seek to implement or expand CDI programs, that type of expertise is expected to become even more valuable. Anecdotally, facilities seeking to bridge expected ICD-10 productivity shortfalls with temporary CDI help could be paying top dollar to consulting or staffing firms–and the firms themselves may struggle to hire as many experienced staff as possible to meet the demand.
The tip here would be to obtain your certification, maintain your ACDIS membership, and stay informed about the nuanced details as they relate to ICD-10. Those who do could be the super-stars of the coming year.
Don’t be discouraged if you do not have experience in the CDI world! According to a recent, AHIMA/TrustHCS study published this summer in Educational Perspectives in Health Informatics and Information Management, more than 80% of all healthcare providers are expected to have a CDI program in place by the end of 2014 with growth areas across all hospital sizes and specialties.
So if you think CDI might be right for you take some time and start doing your research. Here are a couple of ideas to get you started:
- Start looking at CDI job descriptions to see if you have the right experience levels.
- Sign up for CDI Strategies and subscribe to the ACDIS Blog. Both are free and open to the public so you can become familiar with the issues while you’re making up your mind whether you want to get more involved.
- Join ACDIS and review the sample CDI specialist job descriptions and training materials available in the Forms & Tools Library. These are the tools that CDI programs around the country are using to help get their staff up to speed. Those who are familiar with the roles, responsibilities, expectations, and issues headed into an interview will be two-steps ahead of their competitors.
- If you work in a facility with an existing CDI program, approach your colleagues and ask them what they like and don’t like about the job. Ask them how their interviews for the position went.
- If you are not comfortable asking your own coworkers (or if you do not have a CDI program currently) reach out to a neighboring facility and ask if their manager/team would mind if you job shadowed them for a day to find out if the position is all that you expect it might be.
- Join your ACDIS Local Chapter and be sure to network. Chapter members, like ACDIS national members, are generous with their time and advice and are typically willing to offer any tips they can to help expand the profession.
Well, these were the ideas that the two of us were able to knock around during our brief discussion at any rate. Please feel free to add any suggestions, thoughts, or recommendations you may have to help encourage others to join this great—and growing—profession!
As you know, ACDIS is a community of CDI professionals who share the latest tested tools and strategies to implement successful CDI programs and achieve professional growth. To that end, its members have already shared a host of useful materials on our Forms & Tools Library. It is one of the most popular aspects of ACDIS membership. And we want you to be a part of it. Our goal is to feature your sample queries, physician education items, policies, and job descriptions.
Query forms should be compliant with the latest ACDIS and/or AHIMA guidance and should have been reviewed for valid clinical indicators within the most recent calendar year. We are particularly seeking:
- Query forms specifically for pediatric conditions
- Queries which have been updated for ICD-10-CM/PCS documentation requirements
- Physician training materials for ICD-10-CM/PCS
- Sample job descriptions for physician advisors, CDI managers/directors, CDI specialists
- Training materials for new CDI specialists
Materials will be reviewed by the ACDIS Forms & Tools Library Committee. If your donations are chosen for the library you will receive a $50 coupon to use on any HCPro product. To contribute, please email your submission to Melissa Varnavas at firstname.lastname@example.org. Thank you for your continued interest and support for ACDIS.
Dear CDI professionals and ACDIS members,
Please take a few minutes to participate in this CDI program structure and productivity survey. In it, we ask questions regarding your CDI program’s reporting structure, the number of record reviews you perform and whether your facility plans to hire new CDI staff to respond to the documentation and training needs associated with ICD-10-CM/PCS implementation. Your responses will illustrate program structure and productivity trends across the country. We hope the results will help you draw meaningful comparisons with other CDI programs across the country and build a case for hiring additional staff.
To participate in the survey, click here.
By James S. Kennedy, MD, CCS, CDIP
Although most physicians have heard of DRGs with inpatient admissions, only those invested in accountable care organizations and independent practice associations are likely familiar with hierarchical conditions classifications (HCCs). Based on ICD-9-CM codes submitted by physicians or hospitals in a calendar year for documented diagnoses requiring assessment, management, or treatment, HCCs will significantly change in 2014 with additions and deletions as well as relative weight changes.
Physicians documentation will need to improve related to HCCs because one of the goals of the Patient Protection and Affordable Care Act (PPACA) is to encourage provider efficiency, defined by CMS as a ratio of observed to expected costs and outcomes for selected populations. And, to this end, CMS is developing efficiency measurement metrics that will influence reimbursement and may be reported on its Physician Compare website (http://tinyurl.com/ mnq89rh). These include:
- CMS Episode Grouper for Medicare. Part of CMS’ Quality and Resource Use Reports, currently focused on cardiac conditions and pneumonia. Learn more at http://tinyurl.com/2013CMSEG.
- CMS Physician Value-Based Payment Modifier. Applicable to groups of 100 or more providers in calendar year (CY) 2015, potentially groups of 10 or more providers in CY2016, and all others in CY2017, its calculation involves the total per capita cost measure for Medicare fee-for-service and the Medicare spending per beneficiary models using CMS’ HCCs. Read more in the CY2014 CMS Proposed Physician Fee Schedule, available at http://www.gpo.gov/fdsys/pkg/FR- 2013-07-19/pdf/2013-16547.pdf
Editor’s note: This article is an excerpt from the Featured Article on the ACDIS homepage and was originally published in the December 2013 edition of Medical Records Briefings. James S. Kennedy, MD, CCS, CDIP, is president of CDIMD.com. A past ACDIS Advisory Board member, Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at email@example.com.