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Alphabet soup: Five CMS acronyms every CDI should know

Okay, I know there are ton of other acronyms that clinical documentation improvement specialists



need to know, not the least of which include CC, MCC, DRG, POA, HAC, CHF, CKD, ARF, (don’t forget about the biggy—CMS!) and so on. . .

On the tail of my last post regarding recovery audit contractors I noticed a number of other data collection government groups associated with CMS that clinical documentation folks may or may not be aware of. I thought maybe you’d find a quick rundown of these acronyms helpful. A note of caution, however, I pulled the definitions from various helpful public Web sites so consider these more like Grandma’s recipes than the combination to the safe that hides the list of well-guarded Campbell’s  ingredients.

  1. Quality Improvement Organizations (QIO): The mission of the QIO is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. In August 2008, work began on the QIO Program’s 9th Statement of Work, which extends through July 31, 2011.
  2. Comprehensive Error Rate Testing (CERT): One of two CMS programs to monitor and report Medicare payment inaccuracies.  CERT measures the error rate for claims submitted to Carriers, Durable Medical Equipment Regional Carriers (DMERCs), and Fiscal Intermediaries (FIs).
  3. Hospital Payment Monitoring Program (HPMP): The second of two CMS programs to monitor and report Medicare payment inaccuracies.The HPMP measures the error rate for the Quality Improvement Organizations (QIOs).
  4. Program for Evaluating Payment Patterns  Electronic Report (PEPPER): An electronic data report containing hospital-specific data for a number of target areas specific Diagnosis Related Groups (DRGs) and discharges that have been identified as at high risk for payment errors.
  5. Recovery Audit Contractors (RACs): The Recovery Audit Contractor (RAC) program was created through the Medicare Modernization Act of 2003 to identify and recover improper Medicare payments paid to healthcare providers and will become permanent for all states by January 1, 2010.

You should be ready to take the CMS quiz now. . . either that or you’re longing for the days when such ABC mashups meant merely another bowl of soup. Nevertheless, this Scrabble-esque snap shot illustrates just how many ways the government uses data to monitor healthcare services from both a quality perspective and a financial perspective. Where data meets documentation. . . that’s where CDI comes in.

CDI programs have place at the RAC prep table

Since the demonstration program launched in 2005, all the talk’s centered around RACs. But why should clinical documentation improvement specialists care about Recovery Audit Contractors? Isn’t that something for the C-suite, the finance folks, and maybe HIM? Well, yes. . . and no. Preparing for RAC audits requires a team approach and while each of the aforementioned groups maintain important roles, CDI programs do to.

RACs came about, as many of you already know, via the 2003 Medicare Improvement and Modernization Act. Medicare contracts with third parties to analyze data in an effort to

  • Reduce improper payments
  • Collect overpayments
  • Identify underpayments
  • Implement actions to prevent future improper payments

During the course of the demonstration program CMS collected more than $1 billion in improper payments—approximately 96% of which were overpayments collected from providers.  Ond only 4% were underpayments repaid to providers

With such a windfall, it didn’t take CMS long to approve the continuation of the RAC program. Its nationwide rollout should be complete by August so the days spent dreaming of the RACs’ demise are over.

The RAC permanent program currently being rolled out is expected to focus on:

  • Services Medicare deems not medically necessary
  • Services rendered in inappropriate settings (such as service provided inpatient that should have been outpatient)
  • Payments made for incorrectly coded services

All these areas just happen to be ones CDI professionals care about. Furthermore, when the RACs focus on specific clinical documentation problems, facilities with CDI programs in place will have an advantage.

The first thing for CDI program management to do is participate in their facility’s RAC planning team, says Catherine O’Leary, RN, BSN, managing director and founding partner at CSG Health Solutions, LLC. O’Leary will discuss this in her upcoming presentation “The RAC experience: Use your CDI program to proactively address the RAC audits,” slated for Friday, May 15, 8 a.m., in Palace Ballroom III, at Caesars Palace, Las Vegas.

That’s been Mike Alcorn’s experience so far as well. Alcorn, LVN, director of clinical documentation improvement at North Cypress (TX) Medical Center, sits on a RAC team to gather information and monitor RAC hot-button items. The team includes administrators in case management, HIM, quality assurance, and the C-suite.

While CDI programs certainly shouldn’t be looked to as RAC cures, CDI professionals can bring their understanding of many documentation issues into the RAC discussionsto help minimize the effects of the auditors on their hospital.

Happy Birthday AMA!

I subscribe to Garrison Keillor’s Writer’s Almanac; an e-newsletter version of the radio program by the same name. You may know Keillor from the radio program “A Prairie Home Companion.”

This was part of today’s entry.

“On this day in 1847, the American Medical Association was founded in Philadelphia. It was started by a small group of physicians who realized that medicine might work better if doctors talked to each other and shared their practices.”

It’s just my opinion but maybe they were onto something. . .

Malnutrition continues to be area of clinical concern

Generally we don’t think about malnutrition affecting us in modern-day America. The word itself raises thoughts of third-world countries and poverty stricken villages. But malnutrition also affects the elderly, infirm, and critically ill. Appropriate documentation of the various clinical indications of multiple types of malnutrition may make a significant difference in the type of care the patient receives and, ultimately, reimbursement for that care.

The coding of malnutrition needs to be carefully looked upon, says Gloryanne Bryant, RHIA, CCS, senior director corporate coding and HIM compliance department at Catholic Healthcare West in San Francisco.

The condition/diagnosis of “protein malnutrition” indexes to ICD-9-CM code 260 and this represents Kwashiorkor, which is a MCC but a rather rare type of malnutrition in the US population. Then there is other severe protein-calorie malnutrition, which indexes to ICD-9-CM code 262. And then the category for the 263.x range of malnutrition codes, with the overall title of other and unspecified protein-calorie malnutrition and included here are several codes, including: mild and moderate degree of malnutrition.

Bryant adds, “we’re hearing there may be some changes in the indexing for malnutrition in October, so this will be something to watch.”

CDI professionals should brush up on their malnutrition knowledge both clinically and from the health information management perspective. Make sure to tap the inherent knowledge of your physician friends and coding colleagues to draft appropriate queries and capture accurate documentation in the medical record.

Physician query benchmarking report released

More than 350 people responded to the 20-question physician query benchmarking survey launched earlier this year. The survey asked respondents  a wide range of physician query questions:

  • What should you query?
  • When should you query?
  • How should you query?
  • Why should you query?
  • What information do you need to track once physicians respond?
  • What’s the best way to track CDI information?
  • And oh, by the way, how often do you do all this?

Most CDI professionals want to know how other facilities fare in getting physicians to respond to queries. In response to question 18 on the survey, 19% said they have an 81%-90% response rate, followed by 17% with a 71%-80% response rate. Thirteen percent of respondents say they’ve achieved a 96%-100% response rate.

ACDIS members have full access to this report at, click on the “Helpful Resources” section and scroll down to the links beneath the White Paper title.

CDI implications included in IPPS proposed rule

The long-awaited fiscal year (FY) 2010 Inpatient Prospective Payment System (IPPS) proposed rule is out, and with it comes good and bad news for hospitals. Hospitals will see historically low payment updates with a phased-in documentation and coding adjustment (DCA) to take place over time.

The proposed update for acute care hospitals means an update of 2.1% for inflation minus a DCA of 1.9 percentage points. Long-term care hospitals will see a proposed update of 2.4% for inflation minus a DCA of 1.8 percentage points. These DCA adjustments reflect the differences between the changes in documentation and coding that do not reflect real changes in case-mix for discharges occurring during FY 2008, according to CMS.

These low rates won’t help hospitals struggling to keep their doors open in the midst of a worsening economy. “Hospitals that are counting on some sort of increase won’t really see anything this year,” says Kimberly Hoy, JD, CPC, director of Medicare compliance for HCPro, Inc. in Marblehead, MA. “Payments are going to stay flat, and that’s going to be tough for a lot of hospitals.”

Clinical documentation improvement programs as well as more diligent efforts by HIM are most likely the reasons behind more accurate coding that led to higher payments, agrees Shannon McCall, RHIA, CCS, CCS-P, CPC-I, director of HIM and coding for HCPro, Inc. in Marblehead, MA.

“CMS may have underestimated that facilities would create such effective clinical documentation improvement programs,” she says. “I think those programs were an integral part of all of this.”

And in light of decreased payment updates, hospitals that don’t currently have a clinical documentation program will need to think seriously about implementing one, says Gloryanne Bryant, RHIA, CCS, CHW senior director of corporate coding and HIM compliance in San Francisco.

“Hospitals will need to assess their current efforts to capture patient severity and acuity through documentation and coding to see if opportunities remain,” she says.

Prize for 450th and 500th ACDIS conference attendees

Right now there are 432 people registered to attend the second annual ACDIS conference in Las

Only a few more days to the show.

Only a few more days to the show.

Vegas, May 14-15. We think this is going to be a phenominal gathering of professionals. We want you to come too.

So, we’re putting out this little raffle as both extra incentive and a thank you for the tremendous outpouring of support we’ve received so far. 

If you are the 450th person to register for the conference we’ll give you a gift certificate for a free ACDIS audio conference. If you are the 500th person to register for the conference we’ll give you a free copy of the Physician Queries Handbook: Guide to Compliant and Effective Communication writen by CDI experts from FTI Healthcare which will be published later this summer.

The conference boasts more than 24 expert speakers on topics ranging from physician queries to RAC assessment, from severity of illness and risk of mortality to sepsis and respiratory failure documentation challenges, from understanding Medicare’s quality indicators to what not to ask your physicians. There’s important information here for CDI professionals across the continuum.

As everyone knows the most important part of attending such conferences is the ability to network with your peers and meet face-to-face the people who you’ve come to depend through ACDIS. It’s an unbeatable experience.

To register, e-mail our customer serivce ACDIS member relations specialist Susan Calabro at, or by phone at 877/240-6586.

Northern Illinois chapter to meet Thursday

A typical hospital couldn't hold such a stellar collection of CDI staffers!

A typical hospital couldn't hold such a stellar collection of CDI staffers!

Edward Hospital & Health Services bills itself as being “for people who don’t like hopsitals.” So all you hospital-loving CDI professionals heading there for the Northern Illinois CDS meeting this Thursday, April 30, will have to envision yourself meandering more typical healthcare halls as you make your way to the Edward Heart Hospital’s conference room.

From 12:30-3 p.m., the group will gather to share CDI heartbreaks as well as those tips and tricks that make a professional’s pulse quicken. Best of all ACDIS Board Member Robert S. Gold, MD, will be on the phone to talk about CDI quality assessment and the future of CDS programs.  The agenda includes networking and a Q & A session so don’t miss out.

New ACDIS white paper available for download

Hi ACDIS members, I wanted to let you know about a new white paper available for download on the Helpful Resources section of our Web site. It’s called “Roll out an Engaging CDI Program,” and it’s part 2 of a 2-part series about how to sell your CDI program to physicians, and helpful tips and strategies to ensure their participation.

The ideas and best practices in this paper are based on a must-read white paper by the Institute for Healthcare Improvement, “Engaging Physicians in a Shared Quality Agenda.”

You can find instructions for downloading that free white paper on our Helpful Resources page as well.

If you have any comments on this paper, or if you have any suggestions for future white papers, please e-mail me at

Thanks, and happy reading,


Establish a policy to address query form use

Whether your facility handles physician queries specifically within a dedicated CDI program or within your HIM department be sure to get advice from your team of physicians when developing a query policy. With a draft in hand, have your hospital’s HIM and compliance department committees review and approve the policy. And don’t forget to consult the  September 2008 AHIMA physician query practice brief “Managing an effective query process.”

Make sure your draft query form is clear and concise, presents facts from the medical record and identifies the need for clarification based on clinical indications, provides open-ended questions rather than multiple-choice or “yes” or “no” responses. Such specifications help reduce the risk that your query will lead the physician to document a diagnosis that was not clinically accurate.

Your organization’s policy should eliminate the use of general queries. For example, do not make it a policy to query any/all cases without a documented secondary condition. Instead, formulate a policy that allows the facility to query physicians based on indications (or lack thereof) specific to the patient’s treatment.

Editor’s note: This post was adapted from the book Coder Productivity: Tapping your Team’s Talents to Improve Quality and Reduce Accounts Receivable. For information, call 877/727-1728.

ACDIS members have access to sample physician query policies and procedures in the Forms & Tools Library on the ACDIS Web site.