Asset or Liability: How do you describe your CDI program?

A recent discussion on the ACDIS CDI Talk list serve provoked me to ponder: Is your program truly an asset

Don't use measuring tape to determine your CDI program success.

to your organization? Does it promote complete and accurate clinical documentation reflective of patient severity of illness (SOI), medical complexity and quality outcomes that justify the costs of care? Or is your program really a liability to the organization?

The CDI Talk discussion asked how programs calculate their return on investment (ROI). One response pointed out that any monthly report of CDI case mix change and financial reimbursement effectiveness must include a disclaimer informing readers about the fact that such data is subject to adjustment for transfer DRGs provisions inherent in the inpatient prospective payment system (IPPS). So, here’s my two-cents on the issues raised.

Another adjustment to consider

An effective CDI program can be a significant asset or a significant liability depending upon how the program is initially structured, set up, rolled out, and carried forward with daily CDI activity. Unfortunately, a majority of CDI programs center their metrics (proof of their ROI) on increased financial reimbursement to the hospital. This takes away from the overall potential of the CDI program for the hospital as well as the physicians. That’s because this narrow focus on reimbursement positions CDI programs as revenue enhancement programs. It forces CDI specialists to focus on the capture of CCs/MCCs and “more specific” principal diagnosis. And this, in turn increases risk and liability for the hospital.

Consider the following common analysis conducted by CDI programs to prove their effectiveness:

• Number of queries left by the CDI
• Number of queries that change the principal diagnosis
• Number of queries that add a CC/MCC
• Number of physician queries responded positively to by the physician
• Number of physician queries not responded to by the physician
• Number of queries left in the record which the physician did not agree to clarify/add documentation
• Potential capture rate of monthly CC/MCC not obtained due to physician disagreement
• Change in monthly case-mix-index
• Time from admission until record was reviewed and DRG worksheet completed
• Average number of times a record was reviewed per admission

While reviewing these statistics can provide insight into a CDI program’s success, commitment to these types of matrices as the sole indicators of a program’s success can stymie a program.

A primary goal of CDI professionals is to improve overall clinical documentation in the record for purposes of accurate, concise, and effective reporting of patient acuity/SOI, physician clinical judgment, medical decision making, and resource consumption through specificity in documented diagnoses.

One of many “by-products” of this stated goal of CDI is that the resulting reimbursement more closely approximates the care provided. However, strict focus on financial reimbursement benchmarks creates incentives for staff to omit queries that don’t affect payment or increase queries for conditions that do. This, ultimately, artificially creates a rosy ROI picture for the CDI program. It also increases financial risks as auditors data mine, down-code, deny, and ultimately take back reimbursement from erroneously documented and coded cases.

Now you see it, now you don’t

In my experience, many a RAC denial is fundamentally related to CDI program deficiencies. Often a query results in the physician documenting a diagnosis in the record just once. The query may have asked the physician to clarify the principal diagnosis, secondary diagnosis, or sought to add a CC/MCC to the record.

These queries frequently include:

• Aspiration vs. community acquired pneumonia
• Sepsis with change in mental status vs. sepsis with acute encephalopathy
• COPD exacerbation with hypoxemia vs. COPD exacerbation with acute-on-chronic respiratory failure

The physician may respond to the query by including the specified diagnosis or diagnoses in his/her next progress note yet not include these same diagnosis specificity in the continued care progress notes and discharge summary. According to our previously discuss benchmarks, the CDI manager counts the physician’s response as a “win,” and moves on to the next chart review.

The physician’s conclusory diagnostic statement without accompanied discussion of pertinent clinical facts and information constitutes insufficient documentation from an “outsider’s review” perspective. The RAC or other third-party payer retrospective reviews frequently down-code or deny these claims due to such documentation deficiency.

Effective CDI programs should incorporate more than financial measures in their program benchmarking.  Clinical documentation beyond mere diagnostic conclusory statements supporting clinical presentation of the patient as well as the clinical facts of the case is essential for revenue integrity and continuity of care. Consider the following found in the most recent Statement of Work for the RAC:

“Clinical validation is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder.”

Now is an ideal time to consider your answer to the “asset vs. liability” dilemma, take inventory of the processes of your CDI program, and aim for positive process changes in the new year to ensure your program’s contribution to the healthcare organization.

One may wish to determine how many RAC denials were associated with disallowance of principal or secondary diagnoses (CC/MCC) on the basis of insufficient documentation. The continued success of the profession of CDI is predicated upon adapting to changes in the healthcare marketplace. Renewed emphasis on a “visionary” mindset versus complacency will ultimately govern the true success of your CDI program.

Book Excerpt: Tailor ICD-10 documentation education to top MS-DRGs

CDI Specialist's Guide to ICD-10

When tackling ICD-10 training for physicians, speak to them about the current ICD-9 systems as a segue to the transition to ICD-10. Focus on the top 10 common clinical diagnoses that CDI specialist at your facility consistently identify as problematic from a clinical specificity standpoint. If physicians are motivated and conditioned to include specificity in these top clinical diagnoses, the road to a successful transition of clinical documentation under ICD-10 can be established.

Another approach is to run a report of the top 20 MS-DRGs for the most recent fiscal year and review the diagnoses that comprise them. Then tailor ICD-10 training to common clinical diagnoses that physicians manage on a regular basis. Common MS-DRGs that will appear on this list relate to diagnoses such as:

• Chest pain
• gastroenteritis/esophagitis
• Congestive heart failure
• Pneumonia
• Kidney and urinary tract infection
• Cellulities
• Stroke and cardiovascular accident
• Cardiac arrhythmia and other conduction disorders
• Sepsis
• Seizure disorder
• Gastrointestinal bleed and obstruction
• Renal failure
• Acute myocardial infarction

Editor’s Note: This post is an excerpt from The Clinical Documentation Improvement Specialist’s Guide to ICD-10.

Pediatric reviews: Know the rules before you play the game

by Robert S. Gold, MD

Even experienced and consistently accurate acute care hospital coders may not be familiar with pediatric

Don't throw the baby out with the proverbial bathwater when it comes to documentation and coding improvement associated with pediatrics.

diseases. Age is not a factor for some conditions (e.g., appendicitis). Others are age-specific or have age-specific diagnosis, healing, and treatment implications. Coders must consider this when assigning codes and querying physicians.

Consider a Colles’ fracture. It occurs in both children and adults, but the healing process is different because of the growth plates in the pediatric population. Aspiration pneumonia can present in both groups, but the cause may differ anatomically and microbiologically. Bronchospasm in adults likely has a completely different cause than in children. Diabetes may have similar long-term outcomes, but type 1diabetes is more difficult to manage psychosocially than type 2 in the pediatric population.

Numerous examples illustrate the differences between pediatric and adult diseases. Bacterial causes of pneumonia differ based on age group. Cerebral hemorrhage may have the same fatal outcome in children and adults, but rarely the same cause. Physicians must approach causes of respiratory distress in children quite differently. Heart failure is completely different in the two groups. Even the types of cancers that occur in children are different.

[more]

Tales from the Classroom: Abandoning the CC/MCC emphasis

Look for complete documentation in the medical record not just for diagnoses and conditions that improve DRG assignment and increase reimbursement.

As the lead instructor of HCPro’s CDI Boot Camp I have the opportunity to teach new and old (or, rather, experienced) CDI specialists in a live classroom setting. I primarily teach what we call our “open-reg” (that’s shop-talk for open registration) classes which are offered at various dates and locations around the country. However, I am also frequently asked to teach the CDI Boot Camp for a specific facility or a local group of hospitals or hospital system. (In shop-talk, we call this an “onsite” class.) Sometimes the students are all from one facility and other times three (or more) local hospitals band together to bring the CDI Boot Camp to their area.

For those of you who haven’t met me or heard me teach, I am a huge advocate for CDI specialists, whether they are coders, nurses, physicians or mid-level providers (nurse practitioners, physician assistants). I have had all of these types of students in class and I like to think that everyone who comes to my classes takes away at least one thing they can use to improve their program or do their job better.

As someone who has done the job (I was previously the CDI reviewer/manager for a 400-bed acute care facility) I think I am able to address the reality (and the frustrations) of working in the CDI role on a daily basis. And I should say that I see the CDI role as one which affects long-lasting changes in provider behavior and documentation patterns.

On CDI Talk recently Melissa Varnavas, the Assistant Director of ACDIS, posed the question: “What is on your wish list for 2012?” Some suggested they’d wish to change the opinions of those who view the CDI as a revenue enhancement tool. The discussion there reminded me of a experience I once had during a Boot Camp. The individual who introduced me on the first day told the group that their facility was providing the classroom training because “[CDI staff] have to focus on getting the highest DRG, increase the CMI, and really hone in on getting those MCCs and CCs!”

Students in my classes won’t hear me (ever) tell them to query a provider just solely to capture a MCC or CC. And Boot Camp attendees will never hear me tell them to query because one diagnosis results in a higher-paying DRG than another. Of course I teach the concepts of DRG assignment and the difference between an MCC and a CC—that is the world we live in. Medicare is not going to stop using the MS-DRG system just because we don’t like it.

I do not focus on queries for increased reimbursement because I know from experience that when CDI programs stop focusing on the almighty DRG and adjust their efforts to querying whenever greater specificity is required for accurate, specific code assignment, the Case Mix Index improves, facilities start to report complications accurately, quality measures look better and yes, programs also receive what they deserve under the IPPS.

In the above mentioned scenario, that individual’s introduction did not deter me from teaching what I ethically believe are CDI program best practices. I think the students in this particular class, many of whom had been CDI specialists for several years, were relieved to hear me say that: If you do the right thing for the right reason, you’ll do fine in the long run. I believe most of them knew the essence of this all along.

As a member of the ACDIS Advisory Board since its inception as well as the lead CDI Boot Camp instructor I am aware that I do not solely represent myself when I talk to students. I know that I must also present a positive image of the CDI profession and ACDIS and what we are all working so hard to achieve: A complete, accurate written representation of the care provided to patients in our facilities. Nothing more. Nothing less.

There may be people who don’t want to hear that message, but if I’m teaching your CDI team that’s what you’re going to hear.

CDI Productivity Benchmarks (A CDI Talk topic)

ACDIS surveys, reports, and polls, can help answer productivity questions.

There was an excellent conversation string started on CDI Talk a couple of days ago about productivity measures and staffing models. I provided one of my typical responses there and realized that it might be worth developing into a quick, short(er) post.

The original question asked about daily expectations for an individual CDI specialists as far as initiating new cases and following up on existing cases, as well as expectations for reviews per number of discharges per year.

A lot of excellent replies, comments and sharing followed.  I do shy away from quoting any specific response (you know just like Vegas, what happens on CDI Talk stays on CDI Talk), but one of the repeated observations was how difficult it is to come up with a single figure of merit due to a number of program variations such as:

• number of individuals
• program focus
• paper vs electronic record (and which electronic record system a facility uses)
• physician collaboration
• CDI staff experience level and learning curve
• additional roles/focus (ROM/SOI, POA, RAC, core measures, etc.)
• complexity of patients

There are few (if any) true benchmarking resources that I have found outside of ACDIS.  Consultants certainly have their own models but that is not the same as an objective “what is being achieved”.  All three of the following are worth reading carefully.

• 2010 Physician Query Benchmarking Report
• 2010 CDI Program Benchmarking Survey
• April 2010 White Paper on CDI Staffing Survey : The respondents to this survey were mostly managers or leaders and only one response per hospital was permitted.  This report also nicely summarized discussions by the CDI Work Group about factors that affect CDI productivity.
• For an annual volume of discharges, the on-line poll (#36, Dec 2008) suggests a median of around 1,700 discharges/year/CDS.  It shows an interesting distribution, with a big peak at >2,500, and then the next high point the two elements between 1,300 and 1,900.  There are other on-line ACDIS polls that also provide some insight.

Let me briefly summarize some of the ACDIS survey data.  I will use the 2010 Physician Query Benchmarking Report, though the other sources generally agree.

Items that influence productivity:

• Frequency of concurrent review: 58% daily, 24% every other day.
• Majority of queries: 63% written paper based, 20% written electronic, 3% verbal, 12% equal mix written and verbal
• Do you query when there is not a financial impact: 43% always, 44% frequently
• Do you use templates for written queries: 31% always, 36% frequently, 16% sometimes, 13% never.

Direct productivity benchmark measures:

• Do your CD I specialist’s have a set query quota to meet: 56% no, 38% yes (the median point for that query quota appears almost 25% queries).
• Median query rate about 18%
• Median physician response 87% (with a clear break for >70% suggesting an absolute minimum)
• Median Physician agreement 88% (again, >70%)
• Median new charts per day of 12 (majority between 6 & 25)
• Median repeat reviews per day of 12 (most 6 to 20)

Most sources suggest an average combined total of charts reviewed around 25 charts.  Unfortunately, when extrapolating the daily numbers, they don’t match up with what is commonly discussed for an annual productivity model broadly between 1,300 and 1,900 (i.e., 20 to 25 working days a month times 12 new reviews daily times 12 months gets you to >2,400 cases a year).

Specificity for Thanksgiving dinner

I've even seen turkey wrapped in bacon.

Several decades ago, while visiting my grandmother for the holidays, she asked me what I liked to eat. I was a rather picky eater.  But I told her, “GrandB.,” (that’s what I called her then, it is short for Grandmother Butler) “I LOVE dressing.

But she made the dressing with the turkey. And… there were nuts and bits of apples in GrandB.’s dressing. So, I did not eat a single cube.

I told her, “GrandB., I do LOVE rice!”

But while I was thinking of white rice and butter, GrandB. thought she’d make a special rice pilaf. I did not eat a single grain.

I did not get a third chance.  I ate (or didn’t) what GrandB. planned. GrandB. did make good food and I certainly didn’t starve! (One of my fondest memories is of her made-from-scratch donuts, which she usually started at about 4 or 5 in the morning. When we arrived in the kitchen, it smelled so good, and they were still warm!)

What about specificity for Thanksgiving dinner? How badly could the above scenario have gone if my suggestions had altered GrandB.’s “traditional” meal?

I now live in Eastern North Carolina. There are dishes here that I never even heard of when I grew up in Michigan. Here, barbecue is not a red sauce, it is a vinegar and spice kind of thing.  Here they have something called fried okra and something else called greens!

Potatoes: Whipped or mashed? Seasoned? Sour cream or butter? New red potatoes with their skin still on?  Sweet or Idaho?

How about turkey: Baked or fried? Seasoned with what? White or dark?

And vegetables!  Do you make them into casseroles? Do you steam them? Add bacon to your green beans? What are “fixin’s” anyway?? Salads! Where do I even start??

Isn’t this what we as CDI specialists deal with every day? Seeking out the differences between coders and physicians’ understanding of clinical and coding languages just as GrandB. tried to figure out what I meant when I told her I LOVED rice? And just think,  as ICD-10 comes on board, we’ll be able to capture more of the granularity (pun intended).

At any rate, what dish(es) do you most looking forward to during Thanksgiving and how clearly would you need to describe it? I definitely hope you share it here.

I hope everyone enjoys this holiday, their friends and family, and is able to be truly thankful for what we each have. Happy Thanksgiving to all!

Reminder: ACDIS Advisory Board application period closes Nov. 25

The nomination period for the ACDIS Advisory Board is open through November 25, 2011. ACDIS is currently seeking four new volunteers who will:

• Serve as a resource to the ACDIS membership
• Actively participate in industry-related dialogue
• Promoting the value and importance of the CDI profession
• Help lead the association as it continues to grow

Successes and flops

What efforts earn a thumbs-up from your facility?

By Heidi Hillstrom MS, MBA, RN, CCDS

After reading Penny Richards’ blog post, “Do you know who I am?” I wanted to expand on relationship building with physicians.

At my facility, we have a formal introduction process with all of our physicians and resident groups. During this time, we meet with new physicians to explain our CDI program. In addition, we regularly attend physician group meetings, staff meetings, physician quarterly meetings, etc.

Beyond that formal presentation, I find it is our informal interactions which have proved to be invaluable to our program.

I perform medical record reviews on the patient care floors, even if it is an electronic record review. This allows me to see and interact with many physicians on a daily basis. I have conversations with them and it’s not necessarily about documentation. Physicians are people too. Discussions do not always have to be about business or patient care or what is or is not in the medical record. Talk about sports, kids, or upcoming events. Build those bridges to enhance professional relationships.

“The difference between an interaction and a relationship is a matter of frequency. It is a product of quality, depth, and time you spend interacting with another person.” (Bradberry, Travis and Jean Graves. Emotional Intelligence. San Diego: Talent Smart, 2009.)

Relationship building has enhanced our CDI program.  We have seen an increase in response rate, physician collaboration, and overall physician support.

By building bridges and relationships, a physician query becomes more than a nagging piece of paper or electronic note and the query’s author becomes more than a nag—he or she becomes a colleague. The achievement of this camaraderie enhances the ability to develop a documentation partnership between physician and CDI professional.

Penny Richards responds:

Thank you, Heidi, for sending in your comments on my original post.

I know I promised to give readers “five-minute speech” prep ideas, but I’m not a CDI and  have little to offer by way of building relationships with the physician team. I can give you plenty of advice about breaking the ice and kicking off a conversation (I’m a talker and as a former newspaper reporter, have a lot of experience getting people to chat back to me).

When it comes to teaching points with the physician team, however, I bow to your expertise.

I hope ACDIS Blog readers will take a page from Heidi’s book and share suggestions and techniques. What have you done to train physicians and the clinical team on better CDI practices? What worked? What didn’t work?

Send me an email (prichards@cdiassociation.com) and I’ll compile your comments. Yes, this is like an extension of the CDI Week Success Stories that many of you sent. It’s important to share successes. It’s also important to share the efforts that aren’t as successful. Maybe we can come up with a couple of Top 10 Lists… Successes and Flops. Sometimes you learn more by what doesn’t work than by what does!

Editor’s Note: Heidi Hillstrom is a CDI specialist at St. Luke’s Hospital in Duluth, MN, and the co-leader of the Minnesota ACDIS Chapter. Contact her at hhillstrom@slhduluth.com.

Read more in “Celebrate CDI Success.”

A peck of PEPPER, Part 3

Sort through your PEPPER reports to find additional query opportunities.

If you’ve started using your PEPPER to help you identify potential issues at your hospital, good for you!  In this final entry, I’m going to suggest you take it a step further—identifying charts that may fail for lack of medical necessity.

I’m pretty sure that a RAC bounty hunter will jump at the chance to overturn your admissions due to not meeting criteria.  Nobody’s expecting you to become a case manager, but it  behooves all of us to gain an understanding of what documentation may survive a medical necessity audit.

Quite a few of the PEPPER medical necessity target areas involve what might be considered questionable diagnoses—including our old favorites, chest pain, TIA, back pain, and syncope—and some others that you might not have thought of as questionable, such as DRG 314-316 and DRG 393-395, as well as short stays in renal failure, vascular surgery, and heart failure DRGs.  If you are a high outlier, review your short stay patients, to see if their documentation supports an inpatient stay.

InterQual(TM) guidelines now include the condition-specific diagnoses of acute coronary syndrome (ACS), asthma, epilepsy, heart failure, pneumonia, and stroke/TIA, with plans to add many more.   The new guidelines help you determine who qualifies for inpatient and who should stay in an observation status.  If you don’t have access to admission and continued stay criteria, make friends with someone who does, or better yet, ask your manager to give you access and send you to class to learn the basics.  (Some hospitals use Milliman (TM) guidelines, so your mileage may vary.)

Your impact will be on documentation that supports inpatient severity of illness.   The physician admitting a patient for acute onset chest pain or suspected MI needs to understand the importance of documenting a specific diagnosis such as acute MI supported by positive cardiac markers, or unstable angina, any EKG changes that support the diagnosis, and following specific treatment protocols.

It’s not enough for a physician to diagnose pneumonia in a stable patient—the treatment on day one is the same for both observation and acute inpatient status so the difference is in the presentation, and that means documentation.  What is the oxygen saturation?  Did the patient fail outpatient antibiotics?  Is there evidence of abscess or empyema?  Is the pneumonia multilobar?  Are there additional clinical risk factors?

For your TIA patients, a TIA lasting longer than 60 minutes raises the likelihood of meeting inpatient criteria.  Teach your physicians to assess and document the duration of TIA symptoms.  “R/O stroke” won’t allow you to work around TIA, without documentation of specific physical findings consistent with a possible stroke, such as paresis or dysphagia, or confirmation of CVA by CT or MRI.  For your stable heart failure patients, among the requirements for an acute inpatient admission is oxygen saturation below 89% or a sustained heart rate of 100-120 bpm within 24 hours of admission.  Evidence of greater instability, such as hypotension, mental status changes, or heart rate > 120, with IV medications or increased oxygen requirements, may move the patient into an intermediate or critical care status.

In DRG 314 – 316, other circulatory system diagnoses, you might have patients who come back with a vascular complication such as an occluded central line.  Just having a complication is not enough to justify an inpatient stay—is there evidence of a decreased peripheral or femoral pulse?  Did they qualify for an inpatient admission in some other way?  Syncope, DRG 312, may meet inpatient criteria if it is attributed to a cardiovascular drug, reflects evidence of certain arrhythmias or pacemaker failure, or if the patient has known cardiac disease.  Do you see a documentation opportunity there?

Look closely at your short-stay patients, regardless of DRG.  Did they meet criteria because they underwent a procedure on the inpatient list?  Or did the physician not really think about admission status when they wrote the order? Your PEPPER will list your top medical DRGs for one-day stays.  Consider auditing the top DRGs, particularly if they are the non-specific DRGs such as chest pain and syncope, for medical necessity.  Can the top DRGs be explained by a specific patient population your hospital services?  Did the documentation support the status order?  Did the patient leave before the case manager had a chance to review the case?  Does your CM department just do a great job of moving patients through the system?  What processes does your hospital have in place for reviewing short-stays, either concurrently or retroactively?  What documentation improvement processes can you recommend and/or implement?

I was trying to think of some snappy way to join SALT with PEPPER, but all I came up with was the strategic arms limitation talks.   So on that note, don’t try to force documentation to fit when it doesn’t.  But the more you know, the more you can do.

Book Excerpt: Documentation needs to support severity of illness for pulmonary edema

Documentation Strategies to Support Severity of Illness, Second Edition

Fluid in the interstitial spaces in the lung or fluid in the alveoli can be interpreted as pulmonary edema. With severe shortness of breath, it is likely acute pulmonary edema. Chronic pulmonary edema is usually a manifestation of end-stage heart failure. Patients with acute pulmonary edema may present with acute respiratory failure.

Cardiac causes of acute pulmonary edema include:

• Exacerbation of left ventricular heart failure with volume overload in end-stage renal disease (ESRD) patients who have chronic heart failure
• Acute MI whether from coronary occlusion or demand MI
• Accelerated (or malignant) hypertension including the severe hypertension that may occur with thyrotoxicosis, pheochromocytoma, carcinoid syncrome, eclampsia
• Tachyarrhythmia (AF with RVR, supraventricular tachycardia, ventricular tachycardia)
• Takotsubo syndrome (stress cardiomyopathy or apical ballooning syndrome)

Non-cardiac causes of acute pulmonary edema include:

• Pulmonary embolism (venus thrombi, fat or air embolism)
• Aspiration of gastric acid
• Sepsis (ARDS)
• Rapid decompression
• Drowning
• Volume overload in ESRD patients who do not have chronic heart failure

Documentation needs

Was this an acute MI (including non-Q wave MI due to ventricular tachycardia, pulmonary embolism, or fat embolus? If so, document it as the cause of the pulmonary edema.

Was there chest trauma, rapid deceleration, sepsis, or ARDS? If so, document that as the cause of the pulmonary edema.

Did the patient aspirate fumes, vapors, gastric acid, or food? If so, document that as the cause of the pulmonary edema.

Is this volume overload related to renal failure with an otherwise stable heart? If so, document it as non-cardiac pulmonary edema.

If this is an ESRD patient with heart failure due to volume overload, state so. For example, write: “Noncompliant patient missed dialysis two days ago, admitted now in volume overload causing exacerbation of chronic diastolic heart failure.”

Editor’s Note: This excerpt was adapted from Documentation Strategies to Support Severity of Illness: Ensure an Accurate Professional Profile, second edition, written by ACDIS Advisory Board member Robert S. Gold, MD.