CDI programs bear the weight of providing a potentially great benefit or a potentially great risk for their organizations, depending on the focus and compliance of their query efforts. CDI programs should include input from their facility compliance officer and legal counsel at various stages of implementation and growth.
Ongoing compliance department involvement can help ensure that CDI queries are structured in a compliant manner and can advise the CDI staff members as to whether query templates are acceptable. Such involvement will help guarantee that your CDI program meets the doctrine and spirit of the existing regulations.
Since CMS represents the nation’s largest healthcare payer, many CDI programs get their start in conducting record reviews for Medicare patients and/or top diagnosis target areas. However, the goal of improved documentation and patient care should be consistent across payers and disease type, not just improved healthcare documentation for patients who happen to have government insurance. In addition, the goal of improved documentation and patient care should not focus only on high-cost services such as acute respiratory failure or any other special circumstance. When there is a lack of consistency in policies and procedures, for example, reviewing Medicare and not private payers, the risk for potential misuse and abuse increases.
Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.
Dear healthcare professional,
HCPro is currently seeking speakers to present at the 2015 Medicare Compliance Forum, to be held October 27–28, 2015, at the Marriott Charleston in Charleston, South Carolina.
Is that special person you or a colleague?
We seek speakers to present on all aspects of Medicare compliance, case management, utilization review, patient status, and the revenue cycle. Hot topics from the 2014 Medicare Compliance Forum include:
- The latest changes to IPPS and OPPS regulations and their impact on the audit landscape
- What the 2-midnight rule means for patient status and medical necessity
- Changes to observation services and the impact of Condition Code 44 on revenue
- Guidance on Part A to B rebilling
- Implementing policies to receive accurate payment for packaged and separately billable labs
- An update on the current OPPS system and the impact of the new comprehensive APCs on Medicare claims
- Strengthening your utilization review committee by reviewing real-world examples of successful reviews and fully understanding the Conditions of Participation
- Engaging your physician advisors to strengthen your utilization review committee determinations
- Leveraging the expertise of clinical documentation improvement specialists
Note: If you don’t see your hot topic listed here, please write and let us know what expertise you can bring to the podium! Original ideas are welcome.
Submission form and deadline
Please click this link: http://app.keysurvey.com/votingmodule/s180/f/727062/56e6/, complete the form, and submit it to us no later than end of day Monday, March 16, 2015. Please be sure to complete all the fields. Leaving the form open for a lengthy period may cause it to “time out,” so you may wish to draft your submission in a separate word document and paste in the appropriate fields to ensure proper transmission. Speakers are welcome to submit more than one session, but must fill out a separate form for each submission.
HCPro will waive admission fees to the Medicare Compliance Forum for all selected speakers and co-speakers. Conference sessions are typically one hour in length, and selected presenters will be expected to submit PowerPoint materials at a later date.
We look forward to hearing from you! If you’d like more information or wish to discuss a speaking topic, please e-mail Editor Jaclyn Fitzgerald at firstname.lastname@example.org and we’ll set up a convenient time to speak by phone.
Q: What should I do if I see a non-compliant query in the chart? Should I remove it, let my co-worker know, or just leave it in the chart?
A: Addressing non-compliant queries can be tricky. The best course of action would be to share your concerns with your supervisor who can then either confirm your perception of the query being non-complaint or could let you know why he or she feels the query is acceptable. Ask your manager or supervisor to go over any internal query policies to help you better understand your facility’s compliance parameters.
Most facilities have standard query policies and procedures which reflect national standards (such as the 2013 AHIMA/ACDIS “Guidelines for Achieving a Compliant Query Practice” brief). They also have processes in place to help co-workers handle questionable query processes.
If there are no policies and procedures in place (or if you and your coworker are only the two CDI staff querying physicians at your facility) you may want to review the latest query practice information together and approach whatever management team is in place to develop such policies yourselves.
If the query is truly non-compliant, I would definitely want the supervisor to address it rather than you doing so on your own. It may be that the individual needs additional training or it may become a potential performance issue. In which case your manager or supervisor needs to know about the situation and may even need to have a documented conversation with the CDI team member who left the query.
You wouldn’t want to remove the query. The physician may have already reviewed it and responded in his or her progress note. If auditors or internal staff later question where that diagnosis came from, no query trail would exist and you may not be privy to those subsequent questions. If the supervisor or program manager determines the query was indeed non-compliant he or she may need to also circle back to discuss the situation with the physician and/or coding team.
Twenty years or so ago, CDI specialists might have been called record reviewers or had a title associated with “optimizing” the documentation in the medical record. In the course of the MS-DRG implementation and related documentation and coding adjustment payment decreases, CMS indicated in its FY IPPS final rule that there is “nothing inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment… supported by documentation in the medical record.” And so facilities began to formalize the CDI role.
As benevolent a mission as CDI may seem to have, for many facilities the focus of concurrent physician queries continues to be identifying information to increase reimbursement. When such efforts do not reflect the care provided to the patient or are conducted in a leading manner, these practices could be construed as fraud–particularly when data patterns appear to illustrate inconsistencies with national norms.
Of course, healthcare providers must ensure the financial solvency of their organizations, just as government officials must ensure the solvency of their healthcare funding programs. Both sides of this fiscal conundrum face growing financial frustration as both sides continue to search for an underlying cause to answer the dilemma of expanding healthcare costs.
Nevertheless, when a facility submits a claim to the federal government for payment of activities that were never provided, it risks being accused of False Claims Act violations, investigations by the office of the Inspector General and in some cases prosecution by the Department of Justice.
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.
The advancement of CDI efforts brings with it unique challenges. As benevolent a mission as CDI may seem to have, for many facilities the focus of concurrent physician queries continues to be “optimizing” information in the medical record in order to increase reimbursement. When such efforts do not reflect the care provided to the patient these practices could be construed as fraud–particularly when data patterns appear to illustrate inconsistencies with national norms.
When AdvanceMed Corporation, the Zone Program Integrity Contractor (ZPIC) for CMS parsed its data, it identified eight aberrant providers all essentially from the same healthcare system. After years of investigations and subsequent negotiations between the facilities and the U.S. Department of Justice (DOJ), the facilities ultimately paid an $8.9 million settlement. The DOJ found, in most cases that “the timing of changes in peer comparison data–from below average to above average–coincided with implementation of CDI programs.”
Similarly, when a 2005 Maryland qui tam case settled for nearly $3 million in June 2009, prosecutors pointed to CDI efforts related to leading queries at the crux of the allegations.
Of course, healthcare providers must ensure the financial solvency of their organizations just as government officials must ensure the solvency of their healthcare funding programs. Both sides of this fiscal conundrum face growing financial frustration as both sides continue to search for an underlying cause to answer the dilemma of expanding healthcare costs. Nevertheless, when a facility submits a claim to the federal government for payment of activities that were never provided it risks being accused of False Claims Act (FCA) violations, investigations by the Office of the Inspector General, and in some cases, prosecution by the DOJ.
Editor’s Note: This excerpt comes from The Physician Queries Handbook, Second Edition, by Marion Kruse, MBA, RN.