By Karen Newhouser, RN, BSN, CCDS, CCS, CCM
Quality. If we had a dollar every time that word is used, we would be wealthy. But money isn’t everything. Just consider the evolution of the CDI profession.
True, the CDI profession was built on a financial platform – it’s how CDI programs got in the door in the early years. Now, the focus in healthcare is quality. Quality is the common theme in many healthcare initiatives. It may seem that quality just surfaced, but it has been on the scene for decades.
Pay-for-performance (P4P) is the umbrella from which all modern-day quality indicators stem since its emergence in the early 2000s—after deficiencies in quality were highlighted on two major reports by the Institute of Medicine, To Err is Human: Building a Safer Health System, in November, 1999, and Crossing the Quality Chasm—A New Health System for the 21st Century, in March, 2001. These reports recommended a sweeping redesign of the health care system to improve quality of care.
In this context, P4P emerged as a way for payers to focus on quality, with the expectation that doing so will also reduce costs. The typical P4P program provides a bonus to health care providers if they meet or exceed agreed-upon quality or performance measures. P4P programs can also impose financial penalties on providers that fail to achieve specified goals or cost savings.
P4P programs can be broken down into both private sector and public sector initiatives. The largest and longest running (2001) is the California’s program. Within the public sector, CMS established a Value-Based Purchasing (VBP) program to provide incentives for physicians and providers to improve the quality and efficiency of care. Most of these programs focused on quality with little, if any, cost consideration.
P4P evolved and grew and the Affordable Care Act further encouraged improvements in quality of care while addressing the subject of cost. Due to CMS’ continuous updates in its IPPS proposed and final rules, a few of the P4P programs worth paying attention to include:
- Hospital Value Based Purchasing Program
- Hospital Readmission Reduction Program
- Hospital Acquired Condition (HAC) Reduction Program
As with most quality measures, establishing present on admission (POA) status is crucial. If one looks at POA with a widely general view, if the patient did not come into the hospital with a particular condition, then they acquired it in the hospital. One element to remember is that POA is not limited to a “Y” (Yes) or “N” (No) determination; a provider may also state that he or she is unsure/unable to determine/doesn’t know if the diagnosis was POA. This POA indicator of “W” is considered to be equivalent to an indicator of “Y” and will exempt the condition from being identified as a HAC.
Similarly, a fourth indicator of “U,” or the documentation is insufficient to determine if the condition was present at the time of inpatient admission, is equivalent to an indicator of “N” in a POA determination where a HAC is identified. It is important to note the words “documentation is insufficient…” in the above indicator explanation. These words should be an indication that a query is warranted in an attempt to obtain sufficient documentation to make a POA determination.
The most important point to understand about these initiatives is that they are risk-adjusted. Reporting agencies have their own risk-adjusted methodologies and most are proprietary; it is not necessary to know the methodology. What is relevant is these methodologies use factors such as chronic and co-morbid conditions to determine the degree of risk. The greater the number of, and/or the more significant, the chronic and co-morbid conditions, the higher the risk.
We all realize that the patient entering the hospital today is much sicker than the patient entering the hospital 20 years ago. That is the role of the CDI specialist—to ensure that the record identifies an appropriate principal diagnosis and reflects all significant reportable secondary conditions to match the care delivered and resources consumed.
We are charged with carrying forward the story of the patients’ encounter. We are, in essence, the editors of a non-fiction story. As we move towards a personal health record in our mobile age, it is imperative that we advocate for the patient and appeal for a complete, accurate account of their health status.
Yes, this is the fuss about quality. Our patients are depending on us. We won’t let them down.
And while it isn’t all about money, I would be remiss in not recognizing the role that money plays in all of the above; however, I leave you with this thought…
Quality doesn’t follow money; money follows quality.
Editor’s note: Newhouser is the director of CDI education for MedPartners CDI in Tampa, Florida, and the 2015 winner of the CDI Professional of the Year award. Contact her at KarenMPU@medpartnershim.com. This article originally appeared in the CDI Horizons newsletter.
Healthcare organizations spent approximately $471 billion on paperwork related to billing and insurance in 2012, with 80% of that potentially wasted, according to the study “Billing and insurance-related administrative costs in United States’ health care: synthesis of micro-costing evidence,” published in BMC Health Services Research.
Using a standard definition of “billing and insurance-related costs” (BIR), researchers found that physician practices spent approximately $70 billion, hospitals spent roughly $74 billion, and other institutions (e.g., nursing homes, home health care agencies, prescription drug, and medical supply companies) spent approximately $94 billion. Private insurers spent approximately $198 billion on BIR compared to $35 billion spent by government-sponsored health insurance programs.
Adopting a simplified, single-payer insurance system similar to Medicare could save the U.S. approximately $375 billion annually or more than $1 trillion in three years.
Editor’s Note: This article originally published in the HIM-HIPAA Insider.
The legibility of physician documentation continues to be a concern. Even as facilities implement electronic health record systems, many others continue to struggle with paper records, printed attestation sheets, and other hard copy medical record reports. One of the principal concerns of the printed/paper world comes from famously illegible physician handwriting and perhaps most troublesome illegible physician signatures.
CDI professionals still battling this one out with their physicians, do have some supportive tools from CMS.
So when physicians challenge you, and ask “where does it say that my signature has to be legible?” (Let’s hope you never actually have to hear that said out loud, geez!) you can quickly print out these regulations and show them
The last link brings you to a page of related articles at the CMS.gov website. To find these links I simply accessed CMS.gov, clicked the tab for Medicare and then searched for information related to physician legibility.
This is a hot topic as we do not wish to lose reimbursement because we can’t read the handwriting or identify the signature. That is just lost money for no good reason.
Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into our CDI archives to highlight some salient CDI tid-bit. This week’s installment comes from the July 2012 edition of the CDI Journal.
by Trey La Charité, MD
We all agree: Better medical record documentation helps the patient, the physician, and the hospital. So why do we have so much trouble getting physicians to implement suggestions made by the CDI staff ? If your facility is anything like mine, provider compliance varies greatly. What always amazes me and our CDI specialists here is which physicians participate and which do not. Let’s look at some reasons why physicians choose not to adopt CDI goals and what remedies we might implement to gain wider acceptance of CDI principles.
First, the inescapable elephant in the room that must be effectively and decisively crushed is money. Unfortunately, the gut reaction of most doctors is that CDI is something that benefits only the hospital through an increased profit margin. While CDI professionals know this is not true, this initial reaction is understandable. After all, from where does the impetus for most CDI programs originate? The chief financial officer’s (CFO) office, of course! And, frequently, the CFO has jumped onto the CDI bandwagon because he or she learned how another facility improved their case-mix index (CMI) by implementing CDI initiatives. Although the CMI is merely a reflection of how sick the patients are in a hospital, to a CFO, a higher CMI simply equals greater revenue.
Unfortunately, this means that your fledgling CDI program may have a public relations problem before it ever gets off the ground.
How do we remedy this problem? Education, education, education! The majority of doctors do not understand the increasing availability of their performance data to the general public, the insurance companies, and our government. Why is this important? Our government (via new Medicare payment rules) has embarked on a strategy of healthcare reform through forced competition between healthcare providers. The theory is that patients will choose the doctors and facilities that have better outcomes and fewer complications at a lower cost.
Additionally, insurance companies and employers will intentionally steer their beneficiaries and employees toward the providers who display these same qualities. The ultimate question becomes whether new patients will want (after reviewing performance data on the Internet) or be able (through reduced copays to see the better providers) to be treated by your physicians in your hospitals. Yes, the probable short-term goal of any new CDI program is increased revenue at the CFO’s behest. The long term goal of all CDI programs is to ensure the flow of new patients through your doors through better performance data.
By Vicki Sullivan Davis, RN
Doesn’t it burn you up when someone says that CDI programs are all about reimbursement? I can feel my face get red when I hear that statement! Of course, I remain composed, smile, and provide politically correct education to the individual. But deep down I have always wanted to say, “You are darn right CDI is about reimbursement! I work hard every day to make sure you and everyone else continue to have a place to work. I make sure our patients have the most updated equipment for imagining, the most advance surgical suites, a bigger emergency department, adequate nurses on the units, food to prepare, patients to see and E/Ms to bill!”
I want to say, “Yes, my job is to help make money for hospital and so is yours!” Every person in this industry needs be concerned with reimbursement; our survival depends on having money to provide resources for our patients! We provide for our futures through cost containment, efficiency monitoring, billing, staffing to volume, charging for supplies, and even decreasing the number of linens stocked in each room. All staff should be concerned with cost containment and revenue growth. CDI specialists are no different! Reimbursement is reimbursement, we just call it different things in different departments. Budgets, staffing, billing levels, supplies, etc.
Without bringing in adequate reimbursement, the hospital would have to close their doors despite anyone’s best efforts to control efficiency and quality. If we are not worried about reimbursement, we would not have the resources to provide services that are important to the community. We would not be able to sit and hold the hand of a dying patient. We would not be able to give out teddy bears to a scared child getting a chemo treatment. We would not be able to provide a warm blanket for a frail, confused, and aging patient. The impact of healthcare reform is so significant that we all must worry about the almighty dollar if we truly care about people.
But just because I say my job has an impact on reimbursement, doesn’t mean that I only focus on reimbursement.
The heart of our program focuses on the patient. As CDI specialists, making sure we capture severity of illness and risk of mortality (SOI/ROM) is essential, and the outcome of capturing SOI/ROM correctly happens to equate to reimbursement. CDI specialists are just charged with finding innovative ways to perpetuate our hospital’s future (for the patient’s sake!) So next time the next someone rants that your CDI program is “all about the money,” be proud he or she took time to notice your program, then smile and hand them a teddy bear.
Editor’s Note: Vicki Sullivan Davis is CDI manager at Cone Health System at Alamance Regional in Burlington, North Carolina, and past-speaker at ACDIS National Conference. Contact her at firstname.lastname@example.org.
Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into our CDI archives to highlight some salient CDI tid-bit. This week’s installment comes from the August 2010 edition of the CDI Journal.
By Laura Legg, RHIT, CCS
Some MS-DRGs are more complex and prone to error than others. What can facilities do to identify and manage these MS-DRGs that are prone to error?
- Short stays
- Three-day stays
- Error-prone DRG assignments
- Put PEPPER to proper use
- Tip: Use PEPPER reports to search for CDI targets
- Back to Life: Let SOI/ROM/PEPPER Invigorate Your CDI Program
If you haven’t seen the OIG report “Medicare Compliance Review of University of Cincinnati Medical Center [UCMC] for Calendar Years 2010 and 2011,” take a look here at the Office of the Inspector General’s (OIG) website.
What you will see is eye-opening: The OIG reviewed a sample of claims that it deemed were improperly billed by the 695-bed hospital, and, by extrapolating the error rate, determined that UCMC owes more than $9.8 million in improper payments.
The next thing you should consider as a CDI specialist is: How can I prevent my hospital from such a similar (potential) catastrophic review by the OIG? By focusing on affecting positive change in clinical documentation that represents “true” documentation improvement vs. a narrowly defined CDI focus on the capture of CCs/MCCs, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, a manager with Accretive Health in Chicago.
CDI specialists tend to look only at solidifying individual diagnoses in the chart, but often ignore equally important supporting information like clinical indicators to support admission to the facility.
“Do we have good solid documentation of the patient’s DRG, or do we have diagnoses with little clinical support? Are we just sending automatic queries?” he asks. “Often we’re not focused on getting a solid, effective, and encompassing history and physical [H&P] that accurately captures the patient’s history of present illness [HPI] reflective of the patient’s severity of illness, signs and symptoms.”
Physicians tend to elaborate on a patient’s past illnesses vs. a patient’s present illness. A sound HPI consists of a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present, Krauss notes. “There is often inconsistent or lack of clinical context for the reason for the admission. Doctors need this context for their billing, and [hospitals] need it for quality,” he says.
OPPS developments shift toward MS-DRG-style payments; eliminates physician certification for inpatient stays
After last year’s OPPS proposed rule debacle, which included a later-than-usual release, data errors that required corrections and a comment extension, and radical changes to E/M, the 2015 OPPS proposed rule released by CMS last week seems relatively benign.
As more facilities face the specter of reimbursement losses related to the Readmission Reduction Program, CDI programs may be asked to take a second look at records to help ensure documentation is adequate to fully support the patient’s diagnoses, says Susan Wallace, MEd, RHIA, CCS, CCDS, CDIP, director of compliance and inpatient consultant at Administrative Consultant Service, LLC, in Shawnee, Okla.
While it may seem like “just one more thing” added to the CDI review plate, Wallace says it needn’t be an onerous project.
First, make sure CDI focuses on more than CC/MCC capture and problem-focused reviews. The readmission reduction targets currently include acute myocardial infarction, congestive heart failure, pneumonia, COPD (also COPD secondary to respiratory failure), stroke and elective hip / knee replacements. Beyond the current readmission reduction program, inpatient quality reporting measures also target hospital-wide readmissions, so appropriate risk-adjustment is important for all admissions. p>Second, reach out to other departments such as case management and quality to discuss how they are evaluating readmissions and brainstorm ways CDI can help.
Thirdly, says Wallace, stay informed. Review your facility’s Quality Net data and be familiar with the codes, diagnoses, and documentation requirements for those conditions.
“The Quality Net report to hospitals includes an appendix with factors used for risk adjustment; facilities can look at that data to compare their own facilities to other state and national statistics,” says Wallace. “That’s information that isn’t typically shared or reviewed, so CDI can look for opportunities there. Simply asking for the report can be a way to open the door and begin communications with the quality department.
Editor’s Note: This article originally published in the June 19 edition of CDI Strategies. If your CDI program is reviewing records with readmission reduction in mind, ACDIS would like to hear from and share your lessons learned in an upcoming CDI Journal article. Send your program description to Associate Director Melissa Varnavas at email@example.com.