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Q&A: Tracking denials

denials poll

Did you know 55% say CDI is involved in the denials management and appeals process?

Q: When looking at denials timelines, what information should be noted?

A: There are many critical time elements to capture during the denial appeals process. It is recommended that you add these to your denials database. If that is not possible, an alternative spreadsheet or database should be developed. The first date to track is the date that the denial or remittance advice (zero or underpayment) was received. The amount of time allowed to file your appeal will vary from payer to payer. When tracking timelines, it is important to note the: [more]

UnitedHealth Group, Inc. vs. the United States of America: The case for CDI

Brian-Murphy

ACDIS Director Brian D. Murphy

Part 3 (to read part 1, click here. To read part 2, click here.)

By Brian D. Murphy

In part 1 of this series, I introduced the developing story of UnitedHealth Group, Inc. vs. the United States of America. In part 2, I detailed the facts of the case. Part 3 looks at the regulations and commentary regarding claims submission to Medicare Advantage and the ramifications for CDI.

Section III of the complaint United States of American ex rel. Benjamin Poehling, explains the payment methodology which UnitedHealth Group, Inc. allegedly manipulated for financial gain. The Medicare program pays Medicare Advantage (MA) organizations a pre-determined monthly amount for each Medicare beneficiary in the plan. The payment amount for each beneficiary is based on their particular risk adjustment factor (RAF) score, which among other factors including the beneficiary’s demographics is impacted by assigned Hierarchical Condition Categories (HCC). [more]

CDI Week Q&A: CDI and Technology

Wall, James

James Wall, RN-TN, BSN, MBA

As part of the seventh annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. James Wall, RN-TN, BSN, MBA, the senior director of clinical documentation improvement at LifePoint Health in Brentwood, Tennessee, and a member of the 2017 CDI Week Committee, answered these questions on CDI and technology. Contact him at james.wall@lpnt.net

Q: How long have you had electronic health records?

A: I am a systems Senior Director of CDI. Since LifePoint has acquired many hospitals, we have assumed a variety of different EHR systems. While there is not a standard EHR, LifePoint uses three main Health Information Systems. Many of our hospitals are totally electronic while others are a hybrid of EHR and paper.

Q: Have there been any real sticking points with the transition to full electronic systems? [more]

Book excerpt: Defining clinical documentation and coding standards in the revenue cycle, integrating real-time auditing, part 2

Lamkin_Elizabeth

by Elizabeth Lamkin, MHA, ACHE

by Elizabeth Lamkin, MHA, ACHE

To reinforce formal documentation education provided to physicians and staff, open chart auditing and real-time education is needed. Effective facilities typically have a CDI program staffed with trained professionals to concurrently audit every open chart and query providers to obtain clarifications and additional documentation when needed.

Placing CDI staff on the clinical units to audit chart documentation in real time and personally interact with physicians and other clinical staff, often helps with education effectiveness as well. The CDI specialist can query the physician to explain why the documentation does not meet criteria or does not really tell the story of the patient’s condition.

[more]

Summer reading: Defining documentation and coding standards in the revenue cycle, part 1

Lamkin_Elizabeth

Elizabeth Lamkin, MHA, ACHE

by Elizabeth Lamkin, MHA, ACHE

Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and sometimes vague rules. A facility’s revenue cycle plan should define the necessary education on documentation, when and how this education will be delivered, and how compliance with education will be reported.

It is difficult to hold physicians and other medical staff accountable for applying the rules if they are not educated on what the most current rules require. Physician engagement increases if education includes why documentation is so important and why it must be done correctly while the patient is still in the hospital. Physicians normally do not receive formal education or training on documentation to meet regulatory and coding criteria in their training programs or through continuing education; therefore, it is up to the hospital to stay current on regulations and documentation rules and to provide training to physicians.

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Q&A: Denial management teams

Have CDI questions?

Have CDI questions?

Q: What guidance do you have for building a denial management team?

A: As with any team, it is important to have the right players working together with identified roles and responsibilities established for each. The members of the denials management team should be representative of departments with a direct tie to the various types of denials. Include the following groups: [more]

Note from the Associate Editorial Director: Thoughts about leadership

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Associate Editorial Director Melissa Varnavas

By Melissa Varnavas

I was just in the office kitchen joking with ACDIS Director Brian Murphy about how I’d always envisioned myself being a bigwig in a national healthcare association.

In our “Meet a Member” articles in the CDI Journal and CDI Strategies, we often ask folks about their first job and about their journey into the world of clinical documentation improvement. My first job was stuffing envelopes with some type of business collateral in the back room of a New England scuba diving shop. I also cleaned a dentist office. My later high school and college years I spent teaching daycare.

I had other jobs, too—secretary for an IT division of LibertyMutual, reporter and then editor of my hometown newspaper, managing editor for a radiology newsletter here with HCPro.

Most of you hail from diverse backgrounds, as well. Many of you worked in ice cream shops or fabric stores; started your careers coding in the neighborhood physician office or as floor nurses in hometown hospitals.

My dream job, that person I always wanted to be when I was little, was either a newspaper reporter or a teacher.

In my current role as the associate editorial director for ACDIS, I’m blessed with being able to work in both these roles. I get to play reporter, to talk to our members, to listen to their stories and retell the tales of their struggles and triumphs, sharing them with the rest of the membership so that we might all learn from their lessons and leverage their wisdom and growth in our own practices.

Over the past decade, we’ve grown together from these shared experiences. Like me, many moving into the CDI profession understand little other than broad concepts about what the position might entail. Those new to CDI learn by on-the-job training, taking a CDI Boot Camp, studying training textbooks, and hopefully through their ACDIS membership as well.

As ACDIS has grown over the past decade, we’ve watched our members’ careers grow, too—from CDI specialists performing record reviews to management roles to directorships over multiple hospital CDI programs.

So, my thought on leadership is this—that like so much in life, one may not set out with the intention of becoming a leader in any particular field or of any particular group but through grace and compassion end up becoming such because they step forward into the unknown, ever curious, ever engaging in the process of continued learning, ever generous with the knowledge they’ve obtained, ever giving back to those bright inquisitive CDI lights coming after them.

Editor’s note: Varnavas is the Associate Editorial Director for ACDIS and has worked with its parent company for nearly 12 years. Contact her at mvarnavas@acdis.org. ACDIS publishes a wide-variety of materials to help CDI professionals advance their careers, including: a position paper on the topic of CDI leadership, one on CDI credentialing, and one about defining CDI roles; a note about the value of the CCDS; a white paper on the topic of CDI career ladders and a sample ladder; two Q&As regarding career advancement; career advice from a CDI leader; and advice as to using the Salary Survey for career advancement.   

Book Excerpt: Understanding basic types of denials

Twist_Tanja

Tanja Twist, MBA/HCM

by Tanja Twist, MBA/HCM

You can’t manage what you don’t understand. So, the first step in any effective denials management program is to develop an understanding of the what constitutes a denial, as well as the different types of denials and their contributing causes.

Capture and categorize denials by their specific reason and dollar value, to deep dive into the type(s) of services being denied, the type of claim, the physician, payer, department, person, or situation that caused the denial. Despite a large number of denial reason codes used throughout the industry, all of them generally tie back to a few basic denial types: medical necessity or clinical denials, and technical denials.

Medical necessity or clinical denials

Medical necessity or clinical denials are typically a top denial reasons for most providers and facilities. They are also known as hard denials, in that they require an appeal to request reconsideration. Denial reasons that fall under this category include:

  • Inpatient criteria not being met
  • Inappropriate use of the emergency room
  • Length of stay
  • Inappropriate level of care

The primary causes of medical necessity denials include:

  • Lack of documentation necessary to support the length of stay
  • Service provided
  • Level of care
  • Reason for admission

Providers must ensure physician and nursing documentation clearly supports the services billed and that the physician’s admission order clearly identifies the level of care. One of the most effective means of ensuring compliance is through the implementation of a CDI program,  either internally or outsourced to a qualified vendor. A successful CDI program facilitates the accurate documentation of a patient’s clinical status and coded data.

Implementing a successful CDI program is typically one of the most challenging pieces of the denials management process, but it is the most important for long-term success. First obtain the support of the executives and physician leadership within the organization and second, but equally important, identify a physician champion to serve as the liaison to the physicians, reviewing chart documentation, and providing feedback on how to prevent denials moving forward.

Technical denials

Any nonclinical denial can be categorized as a technical or preventable denial. Causes of technical denials can range from contract terms and/or language disputes or mistakes related to coding, data, registration, or, charge entry errors, and charge master errors. Other technical denials may be caused by claims submission and follow-up deficiencies and denials pending receipt of further information, such as medical records, itemized bills, an invoice for an implantable device or drug, or receipt of the primary explanation of benefits (EOB) for a secondary payer claim.

All healthcare claims need to be submitted in adherence with federal, state, and individual health plan requirements and all claims need to be submitted in a timely manner. Other claim submission errors can be caused by claims being sent to the wrong address or even the wrong payer. Technical denials are known as soft denials because they can usually be reprocessed by providing a corrected claim or other additional information to the payer.

Editor’s note: This article is an excerpt from HCPro’s new handbook in the Medicare Compliance Training Handbook Series, Denials Management, published in January 2017 and written by Tanja Twist, MBA/HCM. This excerpt originally appeared in the Revenue Cycle Advisor.

Guest Post: The CDI buzz about CMI: What your facility metrics mean

What's your case-mix index?

What’s your case-mix index?

Jocelyn Murray

Jocelyn Murray

By Jocelyn E. Murray, RN, CCDS

There’s no question of the financial sustenance facility case mix index (CMI) provides. An elevated CMI level indicates an increased severity (or acuity weight) in surgical and life sustaining levels of medical care. Facility budgets are formed around the CMI, it is the acuity weight representing the average facility case and therefore reflects upon reimbursement. It makes perfect sense that this marker is a strong point of reference in the financial revenue department and a CFO focus. CMS.gov gives the following description of the CMI:  the average DRG weight relative weight calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges.

We know our financial leaders focus on the CMI on an ongoing basis, but is it a true indicator of our CDI operational assessment and program productivity?

In my opinion, the CMI is a good tool to compare area hospital performance at a similar acuity level for medical and surgical care. We know a comparable facility with a much lower CMI can be a direct reflection on missed documentation and lower acuity weighted diagnostic codes. CDI intervention then consists of a provider education plan to improve documentation and capture the severity. Pre-billed audits ensure the acuity is also captured in final coding. Both are standard elements of the CDI process and program interventions.

It can also be a useful tool to help identify how outpatient CDI focus programs in the ED, short-stay surgery, and observation practice levels help ensure CMI accuracy. The DRG for a patient admission that does not meet medical necessity, indicates the patient’s care could have been provided on an outpatient basis. It could also have a critical impact on the CMI.

The lower weight CMI, as reflected by the DRG in this case, is tossed into the bucket as part of the calculated averaged acuity level for the site. One or two occurrences of low CMI weighted inpatient cases may not be a concern, but a handful of cases would certainly have a detrimental overall effect.

In my first years of CDI program implementation, the facility had a significant drop in the CMI over a couple of months during the summer. I dug into the metric further and discovered the top two acuity case surgeons in both neuro and orthopedic were away on vacation. A significant drop in surgeries occurred, and a small number of high-acuity procedure cases were performed and made available in the in that period’s calculation. Of course, the surgeon’s absence had nothing to do with our CDI program productivity efforts. And yet, the CMI drop was brought to my attention by the chief financial officer (CFO) who questioned the cause as CDI productivity. Together, we reviewed my identified findings and took the opportunity to bring forward critical information to the leadership team. The CMI changes had no reflection on the CDI program impact in the absence of surgical caseloads available during that time period.

CDI programs (CDI) are working at more advanced levels in 2017 and need to focus on understanding how their CMI metrics are effected and how the program responds. One key performance of the CDIP is identification of the root cause with any metric change.  Only then can you can establish a responsive goal and develop an individualized action plan for intervention.

In my case, a report identified the absence of two key surgeons and the effects of their absence on revenue for the facility. It was then up to the executive leadership and chief medical staff to strategize on how to prepare, plan, and focus actions for this type of revenue impact in the future.

Editor’s Note: Murray is a senior CDI consultant, HIM services, at ComforceHealth. Her subject matter expertise includes consultative CDI services, training and education, and implementation of new programs. She has expertise both in program assessment and enhancement to improve the quality, productivity, and effectiveness of CDI programs within an organization. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board.  Contact her at jocelyn.murray@comforcehealth.com.

 

 

Note from the instructor: Increase understanding of pathophysiological concepts for CDI

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Laurie L. Prescott, MSN, RN, CCDS, CDIP

by Laurie L. Prescott, MSN, RN, CCDS, CDIP

CDI specialists depend on clinical indicators to support queries. Hospitals and physicians need clinical indicators to support the validity of documented diagnoses.

Clinical indicators include patient presentation, symptoms and complaints, lab and diagnostic studies, and ordered treatments such as medications, interventions, monitoring, and assessments. You can find clinical indicators in the documentation of nursing and ancillary staff. As part of our work with clinical validation, all CDI specialists and coders have to work with providers to ensure diagnoses are well supported within the record. It is not enough to obtain documentation of a diagnosis; we must ensure the record clearly supports its presence.

To concentrate on these issues, we have developed a new boot camp to help increase understanding of pathophysiological concepts. The Mastering Clinical Concepts in CDI Boot Camp is designed to assist in the process of clinical validity reviews by examining a number of diagnoses common to both CDI and audit challenges. The Boot Camp discusses diagnostic interpretations, signs and symptoms, and common treatments and covers interventions to strengthen students’ knowledge and competence in record review.

These concepts will assist CDI teams in identifying vague or missing diagnoses regarding neuro, respiratory, cardiac, gastric, liver, musculoskeletal, endocrine, and renal diseases among others and increase staff confidence in speaking to providers and working to ensure adequate documentation in the record. During class, we use real-life scenarios to drive discussions about challenging CDI reviews and help our students:

  • Increase your understanding of key pathophysiological concepts
  • Improve the quality of clinical indicators used when you query
  • Cultivate critical thinking skills for use with data involving complex clinical concepts
  • Improve your ability to distinguish evidence-based clinical indicators from other data in the record

I’m looking forward to teaching this new boot camp aimed at experienced CDI professionals looking to advance their careers with next step training. This course is also valuable for coding staff who wish to increase their clinical understanding of the records they review.

We look forward to seeing you in class!

Editor’s note: Prescott is the CDI education director for ACDIS/HCPro. She is a frequent speaker and author of The Clinical Documentation Improvement Specialist’s Complete Training Guide.