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Pre-Conference Q&A: ‘The Physician Advisor’s Role in CDI’

James S. Kennedy, MD, will present a two-day pre-conference regarding the role and responsibilities of physician advisors for CDI.

Editor’s Note: Over the coming days and weeks, we will post a series of Q&As with presenters and participants from the 2012 ACDIS Conference in San Diego. Today’s post features James S. Kennedy, MD, CCS, ACDIS Advisory Board member and a director at FTI Healthcare in Brentwood, Tenn. Kennedy will co-present the ACDIS pre-conference event titled “The Physician Advisor’s Role in CDI: A collaborative approach for success.” The two-day session takes place Tuesday and Wednesday, May 8-9, 8 a.m. to 4 p.m.

Q: What role should CDI physician advisors play in audit review and data analysis?

A: Clinical Documentation Improvement (CDI) physician advisors are critical to the entire process of ensuring the integrity of coded administrative data (ICD-9-CM and CPT) and its application to physician and hospital quality and cost efficiency measurement.

CDI is the process of preventing and reconciling inconsistent, incomplete, imprecise, conflicting, or illegible documentation to bridge the gap between treating physicians and coders. Physician advisors must be able to analyze data derived from these codes to target their efforts and should review the results from documentation audits as to hone their message.

Examples of these activities include:

1. Data Analysis: ICD-9-CM coded administrative data is primarily used to determine, measure, and report severity and risk adjusted outcomes and cost data for various metrics.  These include cost, length of stay, complications, mortality, readmissions, and the like.

   Risk and severity adjustment means that the actual metric being measured (observed) is compared to the likelihood of that metric occurring (expected).  CDI ensures the integrity of the expected metric, usually increasing it since many clinical descriptions are incomplete or imprecise, thus reducing the risk-adjusted metric.

   Take for example the Colorado Hospital Report Card. Note that Colorado reports an actual mortality rate and a “risk-adjusted” mortality rate.  There are instances when the risk-adjusted mortality is less than the actual mortality since the death rate is less than expected.  There are others, however, where the risk-adjusted mortality rate is higher than the actual.

   Another aspect is measuring complications of care.  Some facilities code incidental serosal tears as “accidental lacerations.”  Physician advisors would want to analyze Patient Safety Indicator data at their hospitals (e.g. from Thomson-Reuters, the Delta Group, and the like) to determine if the data driving these metrics is accurate.

   For example, look at the website “CareChex,” a division of the Delta Group, to see how it ranks overall surgical care in Chattanooga, Tenn.

   Physician advisors should partner with their chief quality officer to learn how these risk-adjustment methodologies work and how the definition, diagnosis, documentation, and coding of these conditions factor into them.

   Armed with this information, the physician advisor can help develop systems that work with providers to accurately capture these metrics.

2. Chart Audit: Physician advisors are integral to the chart review, given that they recognize the clinical scenarios that are often not documented completely and precisely.  Imagine a patient admitted with a pH of 7.02, pCO2 of 100 and a pO2 of 40 and stupor requiring mechanical ventilation but only described as respiratory insufficiency with CO2 narcosis. This patient has acute hypercapnic respiratory failure and could potentially be labeled as having a metabolic encephalopathy. The physician advisor recognizes these scenarios and can help concurrent reviewer and coders recognize the circumstances whereby query would be prudent.

AHIMA published a nice summary of the role of the physician advisor, and you read more about the role in the January edition of the CDI Journal.

Q: How can a physician advisor help achieve buy-in from the medical staff for CDI efforts?

A: The best ways I know to achieve buy-in from the medical staff are to:

1. Make CDI an academic exercise, emphasizing the definitions of clinical conditions.  These can include:
1. Transient ischemic attack versus stroke. Note that the 24-hour time frame is completely eliminated.
2. Acute myocardial infarction vs. accelerated angina. Note the critical role of properly calibrating troponins and equating elevated levels with “symptoms of ischemia.”
3. Acute kidney injury.  Note that it is only a rise of the serum creatinine of only 0.3 mg/dl

2. Ask the quality officers of your hospitals to generate individual physician reports regarding their own cost efficiency and outcomes, outlining the actual and the expected outcomes.  Should a physician see that their expected mortality rates is higher than expected and that CDI is a strong solution addressing the “expected” component, his or her participation and interest is likely to increase!

Q: How involved should the physician advisor be in the day-to-day operations of the CDI program?

A: Given that most physician advisors have their own private practices, they do not need to be involved with the direct day-to-day operations of initiating queries. They should, however, be available at designated times to support concurrent reviewers and coders regarding the clinical circumstances assessments of clinical situations requiring query and to aid in their construction.

If at times a physician does not respond, the physician advisor may potentially have a collegial conversation about a query.  One must be cautious, however, to frame this conversation about defining a patient’s condition without putting the physician on the defensive.

One of the fun things a physician advisor can do is support the development of the electronic medical record as to make the capture of complete and precise documentation less onerous to the practicing physician.

Q: What are you looking forward to most about this year’s ACDIS Conference?

A: Wow….what’s not to look forward to? ACDIS is everything a CDI professional, coder, or physician advisor would want—clinical conversations, problem solving, medical informatics, and collegial interaction with like-minded individuals working to solve the challenges we all share.

It’ll be great to be with old friends and make new ones!  Not to mention that all this occurs in downtown San Diego, in a phenomenal setting (this is a beautiful hotel), right next to Balboa Park (let’s rent a bicycle and ride!) and close to Sea World, the ocean, and all that makes southern California great!

I must say, however, that the most anticipated event for me is the Physician Advisor pre-conference where Dr. Trey LaCharité and I spend two days training physicians from all over the nation to understand and embrace CDI principles.

I feel that this contributes to the professional practice of medicine and empowers physicians to successfully negotiate healthcare reform.  Needless to say, I’m very excited about the conference!

Reflections on physician leadership and engagement with CDI programs

Over the past several years there have been a number of conversations that touch on physician leadership involvement with CDI. Programs can and do achieve success, but so much more is achieved when there is a proactive and supportive medical voice.

Physician leadership can come from a number of sources and in a variety of forms. Some CDI programs (a few anyway) report directly or indirectly to a physician executive (medical staff functions, chief medical officer [CMO], etc.) and other programs report to the quality department where a physician executive is frequently directly involved. In these circumstances, I hope the physician executive maintains some amount of time dedicated for CDI efforts.

Some organizations are fortunate enough to have physician leadership within the broader organization that is (or have been convinced to be) very supportive to CDI efforts. From what I’ve heard, these frequently include CMOs and chiefs of staff and/or service lines within a given facility. Finally, some physicians, such as a medical director, physician champion, advisor, or liaison, devote a portion of their time to work directly with CDI. (Read more about the expanding roles and responsibilities of CDI physician advisors in the January 2012 edition of the CDI Journal.)

Furthermore, even with supportive medical staff leadership, how that support translates into action varies. Some facilities provide physicians time to offer educational sessions to their CDI and coding teams. Others provide CDI education sessions to entire physician groups by service line.

Most CDI programs earn physician leadership and support through the tireless efforts of the CDI staff and program leaders. Only occasionally have I seen this support present from the very beginning.

Some Perspectives

I’d like to look at the “state of affairs” in regards to physician leadership.  One ACDIS weekly online poll (2008) addressed the simple question of whether respondents had a “physician champion” and if that champion was effective. That poll was rather surprising; only 46% indicated they had a physician champion, and half of the respondents with a physician champion actually rated him/her as ineffective. So, according to that poll, only 23% of programs have an effective physician advisor.

ACDIS repeated the  poll (with slightly different wording) in April 2011 and though the results showed some improvement, they were still discouraging. In 2011, 31% described having a very beneficial physician champion, 22% described their physician champion as “’minimally effective”, 24% felt the position was not affordable, and 16% indicated that their program could not find a good candidate. Even more surprisingly to me, 7% said they simply did not see the need for the roll.

Additional polls from 2008 which echo the theme of limited physician support for CDI programs include:

• “How have physicians reacted to your CDI program and query requests?” where only 40% reported a positive response from physicians
• “Are your physicians catching on to your CDI program? ” 3% yes, 74% yes and no, 23% no
• “Do you have any physicians who refuse to participate in your CDI program?” where 81% indicated anywhere from one to many physicians refuse

Other recent poll responses illustrate different aspects of physician involvement in CDI , but I thought these painted an interesting picture.

Don’t forget the most recent study, published in the January CDI Journal, in which 73% (178 individuals) indicated that their physician advisor spends five hours or less dedicated to CDI efforts, and 54% described their advisor as either moderately effective or ineffective.

Data

I think it is  important to have data to effectively measure any focus area of interest. I believe a couple of key metric data pieces provide insight to the level of success with physician engagement. In any analysis, I would include items such as:

• Physician response rates
• Severity of illness (SOI)/risk of mortality (ROM) data
• Trends in volume of queries and more specifically the focus of queries (Do CDI staff ask the same queries repeatedly?)

I specifically would not include physician agreement rate except in a broader sense in looking for individual outlier physicians, to find those who either agree to whatever the CDI specialist asks or those who never agree with the premise of a CDI specialist’s query.

As always, I’d love to hear what elements other CDI programs use to statistically validate their physicians’ involvement with and support of their CDI programs.

Resources

Quite a bit of material is available between the ACDIS online polls (I have fun with those, obviously), various blog postings, journal articles, and conference presentations that offer useful information regarding physician engagement. Several provide inspiring examples of successes. Various items from other organizations are in the public domain.

If you are interested, shoot me an e-mail or leave a comment here and I can develop a partial list of links.

Wrap -up

I am sure most agree that fostering physician engagement in CDI efforts is one of the key challenges of every CDI program.

I certainly don’t have many great answers to this question, and I’d like to hear more thoughts, experiences, and success stories. I know some great examples would be wonderful Journal articles or blog posts.

I will toss in a final thought. Organizational cultural change typically takes five years. Certainly obtaining physician interest in documentation and coded data represents a significant cultural change.

Sometimes I wonder if just need to practice a little more persistence and a lot more patience.

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.”

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.

Do you know who I am?

Sometimes causual conversations and simple kindness can open doors for CDI collaboration.

Scenario: You find yourself in the company of a physician you haven’t formally met, but for whom you have left queries (or may in the future). You’re in line behind the doc in the cafeteria or riding the elevator together, and you’re aware this is a great opportunity to say “Hello” and introduce yourself. What should you do?

I hope you put your hand out and start a conversation.

You don’t have to turn it into a big teaching moment. In fact, this might be the wrong moment to try that. Chances are the physician in front of you is lost in thought. Instead, make it a pleasant exchange.

“Hello, you’re Dr. Murphy, right? I’m Penny Richards, I work in the CDI department. I’ve sent you a few queries in the past. I just wanted to introduce myself and say ‘Hello’!”

Make eye contact. Smile. Don’t ask for anything business-related. Don’t ask the status of a pending query.

Keep this first face-to-face meeting upbeat and positive.  If the physician transitions to a business conversation, then by all means, follow—but let him or her take the lead.

Pass your few moments together with light conversation. End your time together with something simple, such as “I’m glad I had a chance to meet you. I look forward to talking with you again.”

Remember: You never get a second chance to make a good first impression.

Ask yourself how you’d like to be greeted? With “Do you know who I am?” or with “Hello, you may not know me, I’m Penny Richards and I’m happy to meet you!”

This easy-in-easy-out greeting style is a great way to establish yourself with the clinical team as someone who is non-confrontational and open to having a conversation rather than an argument.

It’s also a great way to set yourself up to roll out your “Five-Minute Speech” at your next encounter. More on that in a future post.

A change in perspective may help build better physician relationships

I’m an old (and I do mean OLD) ICU nurse. As a working nurse, my relationships with physicians usually centered on getting them to listen to my assessments: Yes, you need to get out of bed and come see this patient who has stopped breathing! And getting them to do what they should to care for the needs of their patients: Yes, I could really use a new central line for the 17 vasoactive infusions you’ve ordered!

I respect their level of education and their place on the food chain, but each physician operates on an individual plane of competency and personality for which I sometimes had to make adaptations in my approach.

Twizzlers. Yum.

When I worked in ICU, there isn’t much I wouldn’t do for a nice, polite doctor who showed respect to me and the patients. I knew how hard it is to become a doctor, and how really hard it is to become a good doctor, so I used to try to help the physicians by writing out a verbal order and having it ready for his or her signature. I would try to have all the necessary supplies ready ahead of time and if something additional was needed, I’d be the first to run to get whatever else was needed. Nice physicians got to sit in my space to write their progress notes. I even shared my Twizzlers.

Conversely, if you were a mean, crotchety doctor who didn’t show respect to nurses or patients, I wouldn’t be necessarily unkind but I certainly wouldn’t go out of my way to make your day better. I probably wouldn’t have your orders written and ready for your signature, I would show you where the supply closet was rather than get your materials ready for you, and I’d most likely not let you use my spot at the nurses’ station to write your notes. And no, no Twizzlers for you.  Ever.  Because you have to be a nice person, first and foremost.

In 2008 I left ICU and became a CDI specialist. Nobody knew what that meant, least of all the doctors. They just knew that I left on Friday wearing a white uniform and stethoscope and came to work on Monday in street clothes, pushing a computer on wheels.

When I was no longer running cardiac outputs or sending off specimens for C.difficile, they could no longer comprehend my new role against their earlier vision of who a nurse is and the role nurses play in patient care. I had to create a new identity and that meant redeveloping my existing relationships.

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Physician collaboration: Identifying the keys to success?

How do you get physicians to work with your CDI program?

Over and over again in CDI Talk, at the ACDIS conference, local chapters, anywhere two CDI professionals have an opportunity to  interact, it seems,  some very common topics arise. One of the most common it seems is how to gain cooperation and collaboration of the medical staff in CDI efforts.

An early ACDIS poll (March 2008) asked: “How have physicians reacted to your CDI program and query requests?” The results showed that only 40% reacted positively and the balance either neutral or negative.

I have yet to find the magic pill (imagine me sitting here singing Jefferson Airplane’s “White Rabbit”) which, once taken, will ensure physician collaboration in CDI efforts. If only one actually existed.

In recent ACDIS post titled “The CDI Evolution,” Juanita B. Seel RN, CCDS, described the organic development of her program. One of the things that really struck me was the apparent shift in response of the medical staff as her program focused more on completeness and accuracy of the medical record and away from financial implications of queries.

This idea— how to improve physician collaboration— has been foremost in my thoughts lately.  At my facility here in North Carolina, we are in the process of recruiting a medical director who will devote 50% of his or her time toward CDI/coding/HIMS and the balance to utilization review and case management, so I’ve been thinking A LOT about how to work effectively with this individual. And I’ve been wondering if ensuring physician collaboration is actually really simple.  Is the key truly as simple as finding the right hook, which is severity of illness / risk of mortality?  But there have been so many other things that have been discussed andtried!

How important are the various avenues employed to deliver information and promote better understanding?

• Newsletters
• Physician group presentations
• Fliers or posters
• Pocket Cards (or small handbooks)
• Individual on-the-floor ’30 second spots’
• The content of the queries, especially if attachments are used
• Web based content / presentations / Q&A
• Case Studies
• Support from:
  • Physician Advisor / Champion
  • Hospital Executives
  • Medical Staff Leadership
• Other??

What are the other things that folks have found to really motivate the medical staff?

• Public profiling data
  • Core Measures
  • Health Grades
• Quality of Medical Care
• Physician E&M billing
  • Support complexity and risks
• Short term, high intensity service line reviews
• I know that some organizations include unanswered queries with the delinquent records
• Other??

This is the single most important challenge that a program MUST overcome to be truly successful. This is one of the most important areas where we can share our success stories, our tools, our unique organizational variations, etc. So, I put it back out to the rest of the CDI community: What has been the single most effective thing that your program has done to engage physicians? AND, what has been the largest barrier for your program to obtaining physician collaboration?

Book Excerpt: Documentation pocket cards as physician training tool

Many programs have developed their own home-grown documentation pocket cards, or tip sheets, based on the clinical topics most apropos to their specific facility. Some handouts are a simple piece of paper developed by the CDI team, whereas others are laminated, elaborately formatted cards from consulting companies distributed as part of the initial implementation program.

In general, a pocket guide explains that physicians must document underlying conditions, not simply the signs and symptoms of the concerns, and link the disease to the underlying cause whenever possible. It also directs physicians to document “suspected,” “likely,” or “probable” in the absence of a definitive diagnosis.

Many facilities include prompts for more specific diagnoses such as systemic inflammatory response syndrome (SIRS) and multiple organ failure and an alphabetical list of important conditions frequently forgotten by physicians, such as:

• Acute exacerbation of chronic obstructive pulmonary disease (COPD)/asthma
• Malnutrition
• Metabolic/respiratory acidosis
• Metabolic/respiratory alkalosis
• Sepsis/severe sepsis/septic shock
• Systolic/diastolic heart failure
• Pneumonia

If generating a tip sheet for your facility, list common nonspecific terms physicians frequently use to describe patient care and compare them to similar ICD-9-CM terms that, when coded, reflect a greater severity of illness (SOI) for the patient. For example, “cystitis” may also be “urosepsis”/ “urinary tract infection (UTI),” or it may be “sepsis due to UTI.” Each term progressively increases the patient’s SOI.(6)

Some tip sheets also include Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) quality measures, history and physical (H&P) documentation, discharge summary consistency, POA, and hospital-acquired conditions (HAC). Employing such cards during both initial and subsequent training programs:

• Ensures everyone speaks the same language
• Promotes facility-wide team building
• Provides additional avenue of education regarding CMS/RAC updates

Editor’s note: This article was taken from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition written by Marion Kruse, MBA, RN, and Heather Taillon, RHIA.

Pamela P. Bensen, MD, MS, FACEP, CEO of Medical Education Programs, Inc. in Buffalo Junction, VA, created a laminated pocket guide for physicians  available in packs of 25.

Persistence helps when providing physician documentation

Stephanie Woody, a CDI specialist at St. Joseph’s Hospital and Medical Center, had this Calvin Coolidge quote on her e-mail signature:

“Nothing in this world can take the place of persistence. Talent will not; nothing is more common than

Keep at physician education efforts and you'll be successful.

unsuccessful people with talent. Genius will not; unrewarded genius is almost a proverb. Education will not: the world is full of educated derelicts. Persistence and determination alone are omnipotent. The slogan “press on” has solved and will solve the problems of the human race.”

Woody also has the quote hanging in her office. She says it’s amazing how much she and her CDI teammate have been able to accomplish by simply sticking to the spirit behind the sentiment.

It reminded me of a 2008 article written by Peggy Taulbee and Teri Sholder CDI professionals from Kettering Health Network in Dayton, OH. As they talked about the success of their program at the time, they included some advice about physician education. “Physician education is a daily goal and a continual challenge,” they wrote. “We take every opportunity to enlighten the physicians about coding, documentation, and quality of care standards.”

In their article, Taulbee and Sholder offered some physician education methods that seemed to work at their facility including:

• Create easy to use to web-based education
• Hang educational posters in physician lounges
• Distribute fliers on units to announce upcoming educational sessions
• Stress the importance of complete documentation on physician and hospital profiles

Many CDI programs employ these tactics. What makes one program more successful than another might be as Coolidge suggests one’s ability to be persistent. Physicians, inundated as they are with directives from all departments, require educational reinforcement. The physician query, when used appropriately, can act as a documentation education tool, of course, but add to it some of the items Taulbee and Sholder recommend and you’ve supported that education exponentially.

This reminds me of a 2010 ACDIS Conference presentation, “Strategies for Achieving Medical Staff Compliance,” by Trey La Charité, MD, physician advisor at University of Tennessee (Knoxville) Memorial Hospital. As part of their CDI program education efforts, the team would regularly pick a group of physicians and perform what La Charité called a “blitz.” During the blitz the team examined every medical record of that group of physicians, hung out in the lounge with them, rounded with them, held educational sessions with them, and provided posters, pocket cards, and other tools to the group. (La Charité’s presentation is located on the Forms & Tools Library.)

Whatever method or methods you chose to help educate physicians and advance your CDI program’s efforts remember Coolidge’s advice and “press on.”

OIG report says CMS should use its own data to target trouble documentation

As CDI specialists, we find ourselves trying to keep the attention of our physician audience. The ability to positively engage the physician depends on continually illuminating the direct correlation between accurate and complete clinical documentation and the ongoing evolution of the business of the practice of medicine.

I call your attention to an October report from the Office of the Inspector General (OIG), Center for Medicare and

All eyes are on physician documentation. Let the doctor's know, too.

Medicaid Services’ Use of Medicare Fee-For-Service Error Rate Data to Identify And Focus On Error-Prone Providers, which essentially found that CMS did not use data from its historical Hospital Payment Monitoring Program (HPMP) and Comprehensive Error Rate Testing (CERT) Program  to identify and focus on providers with the highest rates of mistakes.

HPMP, now part of the CERT program, is charged to measure, monitor, and reduce the incidence of improper fee-for-service inpatient acute care Medicare payments by conducting reviews of inpatient admissions to validate accuracy of code and MS-DRG assignment in addition to issuing determinations of medical necessity. The CERT contractor has assumed responsibilities for inpatient record review for calculating the national fee-for-service Medicare payment error rate.

CMS established the CERT program to calculate a national claims error rate for the entire Medicare Fee-For-Service program. The CERT program calculates the error rates for all Medicare Administrative Contractors (MACs) and, until the transition to MACs is completed, the CERT program will also report on carriers, and fiscal intermediaries (FIs). The CERT:

• Randomly selects a sample of approximately 100,000 claims submitted to carriers, FIs, and MACs during each reporting period
• Requests medical records from the healthcare providers that submitted the claims in the sample
• Reviews the claims in the sample and the associated medical records to see if the claims complied with Medicare coverage, coding, and billing rules, and, if not, assigns errors to the claims
• Classifies cases as a ‘no documentation claim’ counting it as an error where medical records are not submitted by the provider
• Sends providers overpayment letters/notices or makes adjustments for claims that were overpaid or underpaid

The CERT program began in 1996. It reports a national paid claims error rate which is based on dollars paid after the Medicare contractor made its payment decision on the claim. This rate includes fully denied claims. The paid claims error rate is the percentage of total dollars that all Medicare FFS contractors erroneously paid or denied. It is a good indicator of how claim errors in the Medicare FFS Program affect the Medicare trust fund. For fiscal year 2009, the national paid claims error rate was 7.8% equating to $24.1 billion.

The CERT program cannot be considered a measure of the cost of healthcare fraud, however. Since the CERT Program uses random samples to select claims, reviewers are often unable to see provider billing patterns that indicate potential fraud when making payment determinations. The CERT program does not, and cannot, label a claim fraudulent.

This last point of identifying individual physician practice patterns of improper physician claims submission was at the gist of the objectives of this OIG review.

The OIG wanted to find out to what extent CMS and its contractors used HPMP and CERT data between fiscal year 2005 and 2008 to identify error-prone providers and initiate corrective actions to address patterns of improper coding and claims submissions.

This OIG examined CERT and HPMP results between 2205-2008 and identified 740 error-prone providers—providers that had at least one claims error in each of the four years of the audit period. Its analysis of the HPMP error rate data showed 554 providers (21% of all HPMP providers with at least one claim sampled in each of the four years) accounted for 59% of the dollars in error for those providers. A similar analysis of the CERT error rate data for the same period disclosed that 186 providers (1.81% of all CERT providers with at least one claim sampled in each of the four years) accounted for 25% of the dollars in error for those providers. [more]