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Medicare Compliance Review provides new blueprint for CDI efforts

Glenn Krauss

Glenn Krauss

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.


Book Excerpt: Physician queries and the regulatory environment

The Physician Queries Handbook, 2nd ed.

The Physician Queries Handbook, 2nd ed.

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.

Q&A: Multiple choice options on query templates

You've got questions? Let us know!

You’ve got questions? Let us know!

Q: Our CDI department is developing clarification forms and I have voiced concern with some of the templates. For example, the anemia clarification lists many possible diagnoses including aplastic anemia. If the listed condition would not be clinically acceptable based on the clinical indicators and treatment, should this diagnosis even be listed? I did raise the issue with our physician advisor and he is concerned with the forms, too. Personally, I feel we should not list diagnoses that are not clinically accurate for the specific case.

A: The AHIMA query practice briefs (the latest created in affiliation with ACDIS, Guidelines for Achieving a Compliant Query Practice, published in February) state that “reasonable” diagnoses must be listed in multiple choice queries. With that reference in mind, it is therefore inappropriate to include options on a query that are not supported by clinical indicators.

Although it is good those creating the query templates want to be as inclusive of as many types of anemia as possible, sometimes there is only one appropriate/relevant diagnosis. In such situations, it is okay for the query form to have only one specific diagnosis option as long as the form also includes options for “other,” with a line for comments, and “unable to determine.” The risk with query templates is that there needs to be a way to exclude information not applicable to a particular patient during a specific episode of care; the CDI specialist/coder needs to have the ability to edit/customize the template to suit the situation.

Creation of query templates have many benefits, however.

For starters, they provide a comprehensive starting point for the CDI specialist to work from. In a situation where an anemia query is warranted the CDI specialist could pull up the query template and adapt it to that particular patient’s medical record, including relevant clinical indicators and eliminating inappropriate options.

Furthermore, when CDI professionals include multi disciplinary members in the query creation process such efforts can prove educational for all involved. Physicians can offer clinical, diagnostic insight and HIM professionals may offer insight into coding nuances. Such inclusionary efforts at the outset also help to ensure all vested parties work together. In short, it can help ensure support for the CDI program and its documentation improvement efforts

Hope this helps.

Q&A: Anyone on the care team can answer a query and be compliant

Ask your CDI question in the comment section.

Q: For some reason, I was under the impression that a query could be answered by any healthcare provider, even one just doing a review of the case (a fellow hospitalist, for instance). I know that a treatment provider is, of course, the way to go but was wondering about this as an option for getting the query completed and if we do go this route if the record would be able to stand up to a Recovery Audit review.

A:Any member of the treating medical team can answer a query (not just the attending physician) as long as the documentation does not conflict with that of the attending provider. Coding can occur based on the documentation of any licensed independent practitioner (NP, PA, MD, DO or resident), who provides direct treatment.

CDI specialists may leave queries in the medical record addressed to the medical team rather than a particular provider to ensure a timely response as the attending physician may not be making rounds the day the query is issued.

The exception may be electronic medical records that require the query to be addressed to a particular person in which case, it would probably go to the attending, but if possible would be copied to all members of the treating medical team. I previously worked at an academic medical center and we never had a problem with any member of the treating medical team addressing a query.

With that said, the attending physician is ultimately responsible for the medical record, which is why some CDI programs address their queries directly to that individual. But I don’t know of any guidance that says queries can only be issued to the attending physician. The only exception is if there is conflicting documentation in the medical record. In that case the attending physician must provide final clarification.

I think it is also important to address the role of the CDI/UR/CM physician advisor in health record documentation. Although a physician advisor is a practitioner, who can provide direct patient care under the scope of their licensing, it is inappropriate for them to document within the medical record unless they are part of the treating medical team e.g., if the patient is under their care and they are assuming/sharing responsibility for the care of the patient.

In other words, when the physician advisor is responsible for the care/treatment of a patient they can use their knowledge of CDI to ensure accurate documentation within the medical record; however, it is inappropriate for the physician advisor to document in the medical record/answer queries when they are not involved in the care of the particular patient. Documentation under these circumstances can be viewed as fraudulent because it appears the health record is being modified for the purpose of reimbursement or some other outcome metric rather than as part of patient care.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, education director at HCPro, Inc. and an AHIMA-approved ICD-10-CM/PCS trainer in Danvers, MA, answered this question. For information about CDI-related Boot Camps taught by Ericson, visit 

Case-mix index: Use with caution

Don't get mixed up by case-mix index metrics

Many CDI managers use case-mix index (CMI) as the primary metric for determining the success or failure of their program. If the CMI rises in a given month, the CDI staff is doing its job, appropriately querying physicians for the correct principal diagnosis and accompanying complications/comorbidities. If the CMI dips, CDI staff aren’t getting physicians to respond, or aren’t reviewing records thoroughly enough.

Or so goes the common logic.

But using CMI as your solitary or even principal metric for success is fraught with problems. Sure, CMI shows a good snapshot of the type of patients a hospital is treating. But as a cold piece of data in isolation it does not tell the story of what is going on inside  the walls of a given facility. For example, what happens if a high-volume heart surgeon in your hospital takes two weeks’ vacation this summer? Your CMI will dip, perhaps significantly if you work in a small facility. What happens if your   hospital adds an expensive new neurosurgery service line? Your CMI is going to climb. And both of these factors are out of the hands of CDI. Is this the measure you ultimately want to be judged against?

Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS an independent revenue cycle consultant from Madison, Wis., and a member of the ACDIS advisory board, has uncovered another problem with CMI as a CDI metric: It doesn’t account for takebacks from Recovery Auditors (commonly known by their original acryonym RACs), Medicare  Administrative Contractors (MACs), and other audit entities.

Krauss refers to CMI “as the cost to buy the product. We should be using gross margin, instead of CMI. Gross margin is gross increase in case mix—minus the take-backs.That’s the net benefit.”

Krauss cites a New England hospital currently under scrutiny as part of an Office of the Inspector General study. An auditor is reviewing more than 100 records of DRG 252, Other vascular procedures with MCC. These records were selected primarily for the fact that they contained only one MCC.

In many of these charts encephalopathy was written only once in the chart, and without the necessary consistency or continuity.

“Undoubtedly, these MCCs will ultimately be denied by the reviewer,” Krauss says. The result is an artificially high CMI that will come back down. “What is the net benefit if we don’t solidify the chart to remain accurate?” Krauss asks.

Instead of declaring victory after a query results in documentation of a single shaky CC or MCC, Krauss says CDI specialists should pursue “valid and explicit, well orchestrated documentation throughout the chart.” This solidifies the entire chart and ultimately results in a more accurate CMI.

In short, CDI departments shouldn’t ignore CMI. But if you do use it, make sure you account for other contributing factors. Deduct valid auditor recoupments from your numbers. And strive in your efforts to create a strong chart, top to bottom, that can withstand scrutiny. Doing so ensures that your CMI is a true reflection of severity of illness—and not an easy auditor target.

Editor’s Note: This article was originally published in the July 2012 edition of the CDI Journal.

Coding for inpatient postoperative complications requires explicit documentation

Capture appropriate documentation for coding postoperative complications.

Determining when to code a post-surgical complication as opposed to simply considering it to be an expected outcome after surgery can be a complicated task.

A complication is “a condition that occurred after admission that, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least one day in at least 75% of the patients,” according to CMS.

Therefore documentation of a postoperative condition does not necessarily indicate that there is a link between the condition and the surgery, according to Audrey G. Howard, RHIA, senior consultant for 3M Health Information Systems in Atlanta, who will join Cheryl Manchenton, RN, BSN, an inpatient consultant for 3M Health Information System on Thursday, July 12, for a live audio conference “Inpatient Postoperative Complications: Resolve your facility’s documentation and coding concerns.”

For a condition to be considered a postoperative complication all of the following must be true:

  • It must be more than a routinely expected condition or occurrence, and there should be evidence that the provider was evaluating, monitoring, or treating the condition
  • There must be a cause and effect relationship between the care provided and the condition
  • Physician documentation must indicate that the condition is a complication

According to Coding Clinic, Third Quarter, 2009, p.5, “If the physician does not explicitly document whether the condition is a complication of the procedure, then the physician should be queried for clarification.”

Coding Clinic, First Quarter, 2011, pp. 13–14 further emphasizes this point and clarifies that it is the physician’s responsibility to distinguish a condition as a complication, stating that “only a physician can diagnose a condition, and the physician must explicitly document whether the condition is a complication.”

For example, a physician may document a “postoperative ileus,” but it is very common for a patient to have an ileus after surgery, Howard says. Therefore, this alone does not qualify as a postoperative complication.

“If nothing is being evaluated, monitored, [or] treated, increasing nursing care, or increasing the patient’s length of stay, I would not pick up that postop ileus as a secondary diagnosis even though it was documented by the physician,” Howard says.

Editor’s Note: This article first published on

To register for the July 12 program visit