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Note from the Instructor: Take a road trip this summer

road trip

Take a CDI road trip this summer!

by Laurie L. Prescott, RN, MSN, CCDS, CDIP

I recently taught a CDI Boot Camp at a large, multi-site organization, with attendees coming from CDI, HIM, and quality departments from four different sites. We began the week discussing the Official Guidelines for Coding and Reporting, moving through each Major Diagnostic Category (MDC), and talking about concerns related to code assignment and sequencing.

This discussion was very much a review for the attendees who hailed from the CDI and coding departments. The quality staff, however, coming from a variety of roles related to core measures, patient safety indicators, inpatient quality reporting, and hospital value-based purchasing, had continuous lightbulb moments.

One individual literally hit the side of her head and said, “This explains so much. How come we were not taught this before?”

After the first few days, I asked the quality department staff if they have ever told a coder or a CDI specialist that they “coded it wrong.” Almost every attendee raised their hand. I then asked the CDI specialists and the coders if they have ever been told they had coded a record incorrectly by an individual who had no understanding of coding guidelines. Every one of them raised their hands.

We discussed communications with providers, compliant queries, and practices of leading versus non-leading interactions when speaking to providers. Many of those who worked under the umbrella of quality spoke up to say that perhaps their discussions with providers had been leading. They never received education about how to compliantly query a provider for a diagnosis or how to query for removal of a diagnosis.

When we discussed sequencing new rules related to Chronic Obstructive Pulmonary Disease (COPD) and pneumonia, I noticed the quality folks looking at each other and making faces. I stopped the class to ask what was wrong. They responded by asking when the change occurred. When I told them late last year—per guidance from AHA Coding Clinic, Third Quarter 2016—they all sighed and one expressed frustration about not knowing about the change earlier. They had been struggling to understand why admissions for COPD suddenly sky rocketed. One simple discussion answered a question they had been struggling with for months. And, as an added bonus, they learned why the coders were sequencing these diagnoses as they were.

As the week progressed, we talked about the specifics of a number of quality monitors—discussing what populations were included, exclusions, and the adjustments applied to organizations related to reimbursement. Now the coders and the CDI staff were asking why they hadn’t been taught this material before. They began to understand why the quality department was so concerned about the presence or absence of specific diagnoses. The quality staff were saying, “we need your help.” There was a purpose to this class: to knock down silos, learn from each other, and support each other.

I often describe our efforts as a group of individuals driving down a five lane highway. We have coders, CDI specialists, quality staff, case managers/utilization review staff, and denials management all traveling in their own lane. But, we are all heading to the same destination. We are all working to bring success to our organization. We wish to be recognized for the high caliber of care we provide, and consequently reimbursed appropriately for the resources we lend to that effort. Documentation is the key to this successful road trip. The providers are working to navigate safely on this busy highway with only the drivers to direct them.

As we travel down this road, we often swerve into each other’s lane. Often we are forced to swerve because the provider looks for guidance from us, assuming we understand the driver’s manual for the other cars on the road. If we do not understand every other driver’s role and their specific manual, we cannot support each other. We need to keep all our vehicles traveling in the same direction at a safe speed and ensure that as the providers try to cross the road we don’t run them down. It is confusing to providers if the CDI specialists instructs them one way and the denial management team tells them the complete opposite. Then they seek clarification from the quality coordinator and get a third interpretation of the “rules.” The providers are bound to give up and just navigate in the bike lane, never making any actual progress.

So, how do we learn to support each other? We need to step out of our comfort zones and spend some time with the other disciplines driving down that highway. We need to ask questions and answer other’s questions in return. We need to recognize that what we do affects the other’s work and work to support them. Large organizations often foster silos more than smaller organizations as they separate out the job functions more definitively. Often smaller organizations expect one person to wear a number of hats. Even though there are issues with overwhelming one individual, it also breaks down barriers.

Before you panic, I am not suggesting one person does it all. I am suggesting, though, that we intermingle a bit more, shadow different job roles, invite others to shadow us.

Take the road trip together—it’s more fun that way!

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, is a CDI Education Specialist at HCPro in Danvers, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.

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Guest Post: Your CDI team’s role in pneumonia value-based outcomes, part 1

Shannon Newell

Shannon Newell, RHIA, CCS

by Shannon Newell, RHIA, CCS

The selection of a principal diagnosis, secondary diagnosis, present on admission (POA) status, and discharge status on each claim determines whether a pneumonia discharge will be included in Hospital Value-Based Purchasing Program and Hospital Readmissions Reduction Program measures. And effective CDI reviews can capture this documentation.

Pneumonia as a principal diagnosis

CMS includes any discharges with the principal diagnosis of pneumonia (including aspiration pneumonia) in the mortality and readmission outcome measures. Some of these discharges are excluded for various reasons, for example, discharges with a reported discharge status of “against medical advice” are excluded from both measures. The final group of included discharges is referred to as the “cohort.”

Consider the following case studies.

Case study 1: A patient is admitted with pneumonia and acute respiratory failure requiring BiPAP with admission to the ICU along with IV antibiotics for treatment of the underlying pneumonia. Two principal diagnosis options exist–acute respiratory failure or pneumonia. Coding guidelines permit the selection of either option as the principal diagnosis. Today’s CDI teams typically select the option that results in the highest MS-DRG relative weight. Based on current MS-DRG relative weights, the pneumonia would result in the MS-DRG with the highest relative weight, and if it is selected, the discharge would be included in the readmission and mortality outcome cohorts.

Case study 2: A 65-year-old white male with known AIDS is admitted with pneumonia related to his underlying AIDS. Only the pneumonia is addressed during the hospital stay. Based on ICD-10-CM Official Guidelines for Coding and Reporting, AIDS/HIV infection (B20) would be reported as the principal diagnosis, and the HIV-related condition, pneumonia, would be reported as an additional diagnosis. The reporting of AIDS (B20) as principal diagnosis would remove the patient from the pneumonia readmission/mortality cohorts.

Summary

Performance on the CMS 30-day pneumonia readmission and mortality measures adjusts payments received for the Medicare and commercial patient population. By promoting and adopting evidence-based definitions; associated documentation requirements; accurate selection, sequencing, and assignment of POA status; and accurate reporting of discharge status, the CDI team plays a vital role in data integrity for claims-based quality measures.

Editor’s note: This article was previously published in the Revenue Cycle Advisor. Come back to the ACDIS Blog next week for the second part of the article. Newell was previously the director of CDI quality initiatives for Enjoin, but is now retired. Should you have any questions regarding this article, please email ACDIS Editor Linnea Archibald at larchibald@acdis.org. Opinions expressed are that of the author and do not represent HCPro or ACDIS.

 

Guest Post: It begins and ends in Patient Safety

Jocelyn Murray

Jocelyn Murray, RN, CCDS

By Jocelyn E. Murray, RN, CCDS

My CDI journey began at a level one trauma and teaching hospital in New Mexico. I accepted a permanent recruitment position and relocated out west. I shifted my career role from case management into CDI Implementation. There, I reported directly to the Chief Safety Officer, a well-respected medical professor for the university.

The CDI program (CDIP) implementation focus at the university hospital was on patient safety. How else would I be enticed to change scope of practice? I wanted to continue my nursing mission and help insure quality patient care. The CDIP aimed to:

  • Identify documentation omissions
  • Capture unexpected postoperative events
  • Clarify if the events were inclusions of care or unexpected outcomes
  • Identify any adverse effects during the patient encounter

The CDIP focused on improved quality by means of safety and risk identification linked to inpatient care. We provided lunch-and-learn sessions for insight to the medical and surgical provider teams. The forums reviewed quality and safety findings, provided documentation education and launched a query process as part of the CDI review to obtain documentation clarification necessary. The CDI specialist acted in a liaison role to utilization review (UR)/case management, quality, and nursing, and raised awareness of the identified untoward events that occurred during inpatient care. The CDIP brought awareness to the multidisciplinary team and new processes of documentation capture were established. New processes of identification for early intervention were also an indirect result of the awareness.

It’s now eight years later, and CDIP expansion led to a nationwide implementation of necessary CDI software tools, the improvement in financial impact tracking and reporting, capture of secondary comorbid (CC/MCC) diagnoses, and recognition of APR-DRG severity of illness/risk of mortality (SOI/ROM) indicators. All actions assisted in the practice’s more accurate capture of patient acuity and identifying the severity of care provided.

Nevertheless, the CDIP role in quality and safety recognition has never faltered. Quality documentation and Value-Based Purchasing (VBP) data transparency kept a light on patient safety, and the lost revenue impact associated has now been identified. Patient safety indicator (PSI) reviews remain a key component of CDIP practice for documentation excellence. PSIs have a critical impact on practice performance and the identity of PSI exclusions can protect facilities from financial loss. A wide variety of agencies offer public reports comparing both hospitals and physicians, allowing the savvy patient to choose only the safest, highest rated medical and surgical care. Does your program have a clear picture of the report and what impact it makes?

The impact of imprecise documentation with inaccurate coded data is measurable. Consider a random consultant audit of 14 facility records, four of the records identify likely inaccurately coded cases triggering established PSIs. The inaccuracy carries an error weight of greater than 28% on both the practice and provider quality statistics and corresponding revenue impact. CDIP PSI audits are critical; they increase compliance adjustment and the ROI. CDI specialists with quality training insight recognize the key diagnostic terms required to accurately clarify untoward event documentation in a safety audit. The list includes some of the following:

  • Inclusion
  • Exclusion
  • Clinically indicated
  • Necessary
  • Required
  • Inherent
  • Routinely expected

Patient safety queries and documentation integrity education will bring focus towards a greater understanding of the impact these specified diagnostic terms hold. A diagnosis identifying the condition as part of the post-operative and medical care will then also prevent a coded error.

In addition, PSI exclusions, as noted in the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators Enhanced Version 5.0 reference, provide insight into diagnoses that do not meet PSI definition if combined with other acuity indicators. To learn more about quality and safety documentation and reporting, click here. You’ll find great material for provider education as well.

Editor’s note: Murray is a senior CDI consultant for HIM services at ComforceHealth. Her subject matter expertise includes consultative CDI services, training and education, and implementation of new programs. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board. Advice provided is general. Contact Murray at jocelyn.murray@comforcehealth.com.

 

Note from the Associate Editorial Director: CDI Journal focuses on quality

by Melissa Varnavas

Healthcare has often been referred to a both a science and an art. Nevertheless, the healthcare industry continues its hunt for proof of quality healthcare services to, as much as possible, remove the art portion of the art-versus-science debate. That’s why the March/April edition of the CDI Journal pulls from a range of experiences and expertise to examine the many ways CDI efforts touch quality measures.

As Congress continues working to dismantle the Affordable Care Act (ACA), a wide range of vested entities contemplate the future of government payment methods. Hospital value-based purchasing (VBP), part of the ACA, offers a number of incentives—both positive and negative—to more closely tie patient outcomes to reimbursement on a host of measures. VBP represents the most comprehensive government pay-for-performance program, but it’s easy to feel overwhelmed by its various components when also considering the myriad collections of quality-focused programs hospitals and physicians need to navigate.

Quality-tied payments and public reporting measures can seem like the multi-headed Hydra of Greek lore—no sooner has a CDI program focused on, and defeated, one serpent than two other initiatives pop into existence. CDI programs understand the need to expand record review efforts, now that CC/MCC capture isn’t their only documentation goal.

Cheryl Ericson, MS, RN, CCDS, CDIP, does a nice job of summarizing the shift in her “Note from the Advisory Board” on p. 6, and on p. 10, ACDIS Editor Linnea Archibald looks at the various components of CMS’ VBP efforts, including a review of hospital-acquired conditions and present on admissions indicators. These articles help illustrate the complexity of quality concerns.

These aren’t the only measures considered in this issue, either. Advisory Board member Sam Antonios, MD, FACP, SFHM, CCDS, offers three tips for programs to help improve outcomes in regard to readmission reductions on p. 8, and ACDIS member Bonnet Tyndall, RN, CCDS, provides readers with a case study of how her team implemented record reviews for mortalities on p. 19.

All these potential review targets can be daunting, but don’t be intimidated. Take a look through this edition of CDI Journal and note how many of these programs aim to capture some of the diagnoses already found on most CDI programs’ top 10 lists.

As ACDIS CDI Boot Camp instructor Allen Frady, RN, CCDS, CCS, says on p. 22, “times like these are exciting for us CDI nerds.”

Editor’s Note: Varnavas is the Associate Editorial Director for ACDIS, overseeing its various publications and website content. Contact her at mvarnavas@acdis.org.

Guest Post: AMI 30-day mortality measures and CDI – Is your approach ischemic?

Shannon Newell

Shannon Newell

by Shannon Newell, RHIA, CCS

The 30-day all cause acute myocardial infarction (AMI) mortality outcome measure has been linked to hospital payments since the inception of the Hospital Value-Based Purchasing Program (HVBP) in fiscal year 2013. In February 2016, CMS announced that 70% of commercial payers agreed to use the measure as one of the cardiology outcomes linked to payment.

The Medicare Episode Payment Bundle for AMIs, proposed to begin in July 2017, will further link reimbursement to measure performance. Traditional CDI approaches to strengthen data quality in the name of risk of mortality are not sufficient enough to capture the documentation needed under the CMS mortality risk adjustment methodology.

CMS includes any discharges with the principal diagnosis of an AMI in the mortality outcome measure (except for a few exclusions outlined in the methodology, such as discharged against medical advice). The final group of included discharges is referred to as the “cohort.” Consider the following case studies:

Case Study 1

  • Scenario:
    • Admitted with severe unstable angina and diaphoresis with the finding of ST elevation in the anterior leads on an EKG with the initial set of cardiac enzymes being negative
    • Because of the suspicion of acute transmural myocardial infarction (MI), receives TPA infusion
    • Subsequent cardiac enzymes are negative, and at the time of discharge, the physician documents an aborted transmural MI
  • Principal diagnosis:
    • The principal diagnosis would be unstable angina because the AMI was aborted
    • If coronary artery disease is documented, coding guidelines would require selection of this condition as the principal diagnosis
  • AMI mortality cohort:
    • This discharge would be excluded from the AMI mortality cohort with the correct application of coding guidelines for principal diagnosis selection

Case Study 2

  • Scenario:
    • Admitted with subendocardial MI with acute systolic heart failure and cardiogenic pulmonary edema
    • Treated with supplemental oxygen and IV Lasix therapy, and because of the patient’s age, the MI is treated conservatively
  • Principal diagnosis: Two principal diagnosis options exist:
    • Option 1: Acute systolic heart failure
    • Option 2:  Subendocardial MI
  • AMI mortality cohort:
    • Coding guidelines permit the selection of either option as the principal diagnosis
    • Today’s CDI teams typically select the option which will result in the highest MS-DRG relative weight, which will result in attribution of the discharge to the AMI mortality cohort in this case

 

Once a hospital claim goes out the door with the principal diagnosis of AMI, CMS analyzes claims databases to determine if that Medicare beneficiary died within 30 days of discharge (for any reason). If a mortality is identified, CMS attributes the death to the hospital that reported a claim with AMI as the principal diagnosis within 30 days preceding the death.

Each discharge included in the AMI mortality cohort is then risk adjusted to determine the expected rate of mortality. The CMS methodology uses CCs/MCCs, not hierarchical condition categories, to determine the likelihood of death for each discharge.

  • Each CC is comprised of related ICD-10 codes
  • There are a variety of CCs which affect AMI mortality risk adjustment
    • These categories are weighted; some have a more significant effect on risk adjustment than others
    • 12 categories drive 90% of strengthened risk adjustment opportunity
    • Only about 25% of these conditions serve as MS-DRG CCs/MCCs
  • CMS looks for the presence of these conditions in the AMI admission as well as all Part A and (face to face) Part B claims for the 12 months prior to that admission
  • Some of the conditions must be documented prior to the patient’s admission for AMI management or there is no “credit” for risk adjustment

Performance for the CMS 30-day AMI mortality measure adjusts payments received for the Medicare and commercial patient population. This reimbursement is not limited to hospitals; under the Episode Payment Model other providers will be affected as well. Although this is a hospital-centric measure, meaning the measure assesses the hospital’s management quality for the AMI population, documentation and reported codes across the continuum affect the expected risk of mortality, and in turn impact measure performance.

A few questions for CDI and quality programs to consider as they shift initiatives to support value based payments:

  • Does your principal diagnosis selection process consider attribution of discharges to quality measures in addition to MS-DRG relative weights?
  • Does your record review process to support the capture of CCs/MCCs related to mortality only on actual deaths or on the entire denominator included in the measure?
  • Are you focused on the capture of CCs/MCCs which have an effect on CMS’ mortality methodology?
    • The comorbidities in this algorithm differ from those used in other mortality risk adjustment methodologies commonly used in CDI programs today
    • The broad number of comorbid categories requires the CDI and quality teams focus on point of care capture
  • Do the clinical documentation and reported codes in your system’s outpatient settings support the capture of comorbid conditions related to risk adjustment?

Editor’s note: Newell is a Managing Director with CCDI-DQ with extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. Reach her at Sknewell1010@gmail.com.

What is All This Fuss about Quality?

Reach out to your physician advisors, case managers, chief medical officers, vice president of medical affairs, president of the medical staff, and any other supportive individuals in your facility.

The typical P4P program provides a bonus to health care providers if they meet or exceed agreed-upon quality or performance measures.

By Karen Newhouser, RN, BSN, CCDS, CCS, CCM

Quality. If we had a dollar every time that word is used, we would be wealthy. But money isn’t everything. Just consider the evolution of the CDI profession.

True, the CDI profession was built on a financial platform – it’s how CDI programs got in the door in the early years. Now, the focus in healthcare is quality. Quality is the common theme in many healthcare initiatives. It may seem that quality just surfaced, but it has been on the scene for decades.

Pay-for-performance (P4P) is the umbrella from which all modern-day quality indicators stem since its emergence in the early 2000s—after deficiencies in quality were highlighted on two major reports by the Institute of Medicine, To Err is Human: Building a Safer Health System, in November, 1999, and Crossing the Quality ChasmA New Health System for the 21st Century, in March, 2001. These reports recommended a sweeping redesign of the health care system to improve quality of care.

In this context, P4P emerged as a way for payers to focus on quality, with the expectation that doing so will also reduce costs. The typical P4P program provides a bonus to health care providers if they meet or exceed agreed-upon quality or performance measures. P4P programs can also impose financial penalties on providers that fail to achieve specified goals or cost savings.

P4P programs can be broken down into both private sector and public sector initiatives. The largest and longest running (2001) is the California’s program. Within the public sector, CMS established a Value-Based Purchasing (VBP) program to provide incentives for physicians and providers to improve the quality and efficiency of care. Most of these programs focused on quality with little, if any, cost consideration.

P4P evolved and grew and the Affordable Care Act further encouraged improvements in quality of care while addressing the subject of cost. Due to CMS’ continuous updates in its IPPS proposed and final rules, a few of the P4P programs worth paying attention to include:

  • Hospital Value Based Purchasing Program
  • Hospital Readmission Reduction Program
  • Hospital Acquired Condition (HAC) Reduction Program

As with most quality measures, establishing present on admission (POA) status is crucial. If one looks at POA with a widely general view, if the patient did not come into the hospital with a particular condition, then they acquired it in the hospital. One element to remember is that POA is not limited to a “Y” (Yes) or “N” (No) determination; a provider may also state that he or she is unsure/unable to determine/doesn’t know if the diagnosis was POA. This POA indicator of “W” is considered to be equivalent to an indicator of “Y” and will exempt the condition from being identified as a HAC.

Similarly, a fourth indicator of “U,” or the documentation is insufficient to determine if the condition was present at the time of inpatient admission, is equivalent to an indicator of “N” in a POA determination where a HAC is identified. It is important to note the words “documentation is insufficient…” in the above indicator explanation. These words should be an indication that a query is warranted in an attempt to obtain sufficient documentation to make a POA determination.

The most important point to understand about these initiatives is that they are risk-adjusted. Reporting agencies have their own risk-adjusted methodologies and most are proprietary; it is not necessary to know the methodology. What is relevant is these methodologies use factors such as chronic and co-morbid conditions to determine the degree of risk. The greater the number of, and/or the more significant, the chronic and co-morbid conditions, the higher the risk.

We all realize that the patient entering the hospital today is much sicker than the patient entering the hospital 20 years ago. That is the role of the CDI specialist—to ensure that the record identifies an appropriate principal diagnosis and reflects all significant reportable secondary conditions to match the care delivered and resources consumed.

We are charged with carrying forward the story of the patients’ encounter. We are, in essence, the editors of a non-fiction story. As we move towards a personal health record in our mobile age, it is imperative that we advocate for the patient and appeal for a complete, accurate account of their health status.

Yes, this is the fuss about quality. Our patients are depending on us. We won’t let them down.

And while it isn’t all about money, I would be remiss in not recognizing the role that money plays in all of the above; however, I leave you with this thought…

Quality doesn’t follow money; money follows quality.

Editor’s note: Newhouser is the director of CDI education for MedPartners CDI in Tampa, Florida, and the 2015 winner of the CDI Professional of the Year award. Contact her at KarenMPU@medpartnershim.com. This article originally appeared in the CDI Horizons newsletter.

 

TBT: Monitoring CDI efforts for effectiveness

TBT to the 4th Annual CDI Week celebration!

TBT to the 4th Annual CDI Week celebration!

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you most likely wish had been left unpublished. We’ve picked up the theme going back into our archives to highlight some salient tid-bit. Today, we’ve pulled from the fourth annual Clinical Documentation Improvement Week, in which Karen Chase, RNC, BSN, Assistant Director of Clinical Documentation Improvement at Stony Brook University Hospital in Long Island, New York, a 603-bed academic medical center, answers questions regarding program monitoring.

Q: Does your CDI department audit for query accuracy and compliance? If yes, can you describe your process?
A: Yes, but what I do is a manual process at this point. Unfortunately the only program we have is basic, with no computer assisted coding or query program. Everything is sent through e-mail and the staff CC me on all emails. I pick 10 queries per month for each CDI reviewer, pull the chart, and see if they are leading, appropriate, or if anything was missed. I also look to see if the chart was reviewed an appropriate number of times. I look to see:

  • Was the working DRG appropriate?
  • What was the CC/MCC capture rates for that CDI for that week?

It’s not the best way, but I’m not automated yet. We moved to an electronic health record two years ago, about six months after I started, and we are hoping to get a 3M program approved in the near future.

Q:What quality metric does your hospital administration find most helpful/compelling when evaluating the success of your CDI department?
A: In the beginning we tracked the case mix index and saw tremendous increases. But then we became stagnant and had to find other ways to measure our progress. Now we use mortality index, also CC/MCC capture rates by service line. We also take DRGs with triplets and compare quarter to quarter how many have CCs, MCCs, or no CC/MCC, such as DRGs 245-247, 280-282, etc. I have a dashboard with those metrics I show administration.

One of our improvements [last] winter was pneumonia (DRGs 193-195). Through documentation improvement, we brought our MCC capture rate from 19% last year to 27%. We also share success with Patient Safety Indicators (PSI). We also look at quality metrics—core measures metrics like aspirin on arrival—and try to help out our quality department in any way we can. We alert quality when there is a quality issue.

For example, if something flags as a PSI, they give it to me, our [CDI] people review it, and if it’s a documentation issue we can fix and query. If not, I toss it over to quality. Even though quality and CDI are separate, we work well together.

We also do mortality reviews. If a patient dies, I get that chart, we get it coded, and we have an ICU nurse who reviews them for documentation improvement. If she sees something that is a quality of care issue, it goes to the quality department. Quality does more retrospective reviews and we do more realtime reviews and we can pick things up faster with our concurrent reviews.

Guest Post: Expanding CDI focus beyond MS-DRG capture

ICD-10 testing process in play

CMS puts additional emphasis on quality of care for payment purposes in recent address.

The recent ACDIS Radio titled “Resolving Coder and CDI Clashes” presented on February 4 was another thought provocative discussion on an important area for most CDI programs.

Allow me to share my own personal thoughts and comments on the concept of MS-DRG congruence tracking in the hopes of provoking beginning a dialogue on the value even incorporating the MS-DRG tracking into a CDI program. Let’s start by defining the core elements of an effective CDI program.

An effective CDI program strives to demonstrate, collaborate, promote, and continually improve clinical documentation. Its purpose is to ensure that medical record documentation is effective, efficient, concise, coherent, complete, and accurate, and that it supports good patient care and captures quality outcomes.

An integral part of CDI specialists’ day-to-day duties and responsibilities is working closely with physicians and other allied health professionals to make a compelling case for best practice strategies of clinical documentation; documentation which clearly captures the physicians’ effective care choices through their:

  • clinical judgment
  • medical decision making
  • thought processes
  • analytical skills
  • problem solving ability

These elements serve as the fundamental basis for Medicare’s recently reinforced commitment to transitioning away from volume-based, fee-for-service, healthcare reimbursement to one which embraces the “triple aim.” The “triple aim” is a framework developed by the Institute of Healthcare Improvement which calls for simultaneously improving an individual’s experience of care, improving the health of populations, and reducing the per capita costs of the care provided.

Medicare’s goal in this value-based, cost-effective, quality-focus approach to the delivery and payment was summarized best in a January 26, 2015 release titled “Better Care, Smarter Spending, Healthier People: Improving Our Health Care Delivery System.”

Consider the following statements from this fact sheet:

  • Improving the quality and affordability of care received by Americans is, alongside increasing access to it, a core pillar of the Affordable Care Act. The Administration is working to ensure that:
    • Americans receive better care
    • Our health care dollars are spent more wisely
    • We have healthier communities, a healthier economy, and ultimately, a healthier country
  • This means finding better ways to:
    • Deliver care
    • Pay providers
    • Share and utilize information
  • The Affordable Care Act offers many tools to improve the way providers are paid to:
    • Reward quality and value instead of quantity
    • Strengthen care delivery by better integrating and coordinating care for patients
    • Make information more readily available to consumers and providers
  • Doing so will improve:
    • The coordination and integration of healthcare
    • Integration of patients in decision-making
    • The health of patients – with a priority on prevention and wellness

Effective clinical documentation, that is, documentation which best explains the reason for a patient’s care is fundamental to the promotion and achievement of smart effective care choices demanded by all third party payers as well as healthcare care consumers. This means that physicians need to provide (and CDI specialists need to seek out and support):

  • an accurate account of the patient acuity and severity
  • clinical rationale for intensity of services ordered and/or performed
  • medical need for inpatient hospitalization
  • evidence-based medical decision making
  • adherence to and justification for deviating from practice guidelines

In light of the above discussion, I pose the question of whether tracking MS-DRG congruency between the coder and the CDI specialists is realistic, practical, or of any material benefit to true effective clinical documentation improvement programs.

That may be a controversial thought considering how many CDI programs begin and the ongoing focus of many on simple CC/MCC capture rates and MS-DRG optimization, but I think that’s where we, as an industry need to be. What are your thoughts and ideas?

Guest Post: In search of the clinical truth

Cesar M. Limjoco, MD

Cesar M. Limjoco, MD

Editor’s Note: This article was originally published in CDI Monthly, by DCBA, Inc., and shared on the social media network LinkedIn. It has been adapted from its original and is republished here at the invitation and permission of the author and participants.

“Many CDI programs have set as their goals: accurate coding, maximum reimbursement, increased case mix index (CMI) and better risk-adjusted scores,” says Cesar M. Limjoco, MD, vice president of clinical services at DCBA, Inc. in Atlanta, Georgia.

“But are they missing the mark? Are they setting their targets low and setting themselves up for a fall?” Limjoco asks. “The goal sets the tone for one’s actions. The end justifies the means.”

CDI programs with preset agendas can slip into focusing solely on those priorities at the expense of the clinical truth, he warns. Like a racehorse wearing blinders to limit distractions, CDI specialists can be blinded to all but the racetrack before them. Without a broad perspective they may have a tendency to arrive at incorrect conclusions, he says. For example, if these end goals take precedence it becomes easier to see (and query for) a variety of diagnoses that may not be true given the entire picture of the patient’s condition, Limjoco says.

“As you may have heard before, medicine is both an art and a science. A provider does not come up with a diagnosis just from laboratory and other workup. There are false positive and false negative results. The provider has to marry the workup results with the clinical picture of the patient,” he says.

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Free Optum webcast rescheduled for CDI Week; additional free webinar on PSI and CDI offered

Join us this for these free audioconference/webinars

Join us this for these free audio conference/ webinars.

Natural language processing (NLP), an emerging technology for CDI professionals, can help drive clinically relevant queries and optimize physician engagement in your CDI program. Learn how Optum360™ case finding technology, powered by LifeCode® NLP technology, can transform your CDI program during this free one-hour webinar on September 17, 1 to 2 p.m. ET.

Join Kelly Gates, RN, MHA, CCDS, and Tom Darr, MD, as they showcase the “next generation” of CDI software, expanding on how technology can perform checks and balances between documented diagnoses and clinical indicators. This enables CDI specialists to quickly and efficiently review potential query opportunities. Clinical indicators identified by the technology route to the CDI specialist for review, and are automatically included in the physician query. These new tools optimize manual tasks, and result in improved response and adoption by physicians.

Click here to learn more about this webcast.

In addition, to kick off CDI Week, ACDIS is offering a 60-minute free webcast on Tuesday, September 16, at 1 p.m. (ET) regarding the role of CDI specialists in review of Patient Safety Indicators (PSI) on a concurrent basis. Join Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer, as she explains PSIs and their function as well as the CDI specialists’ role in their review. The program will also take a deeper dive into PSI 90 to help CDIs focus on the required documentation elements in the medical record and provide practical tips for working in conjunction with quality.

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