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Post ICD-10 Clinical Documentation Improvement (CDI) Program RevitalizationNorth Carolina Health Information Management Association
• Assess previous state (ICD-9) of CDI program against current state post ICD-10
• Identify and leverage leading practices in clinical documentation and when to modify program with ICD-10
• Discuss impact ICD-10 has had on CDI programs
• Discuss impact of technology systems with CDI programs
• Discuss key performance metrics to monitor CDI program’s operations and success
• Better understanding of reimbursement systems
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Introduction
Previous state
Current state
Revitalization of a CDI program is a proactive step that an organization may take to trend towards leading practices and enhance the quality of an existing program.
• What were our processes?• How was performance
tracked and monitored?• What technology was
used?• What was our program
visibility?
• Have our processes changed?• Did we modify our tracking and
monitoring?• What are our technology needs?• How visible is our program?
Beginning with a state-to-state assessment can allow for identification of gaps, changes, and improvements.
• Strong and consistent operational leaders and managers
• Teaming and communication between CDI Specialists, Coders and Physicians
Clinical Documentation Governance
• Physician and executive leadership engagement
• Physician communication• Alignment with related
enterprise initiatives (e.g., system replacement)
Enterprise Technologies & Tools
• Operational tools to drive daily workflow, documentation and tracking of work and exceptions flagging
• Clinical documentation customized query templates within the EMR and/or CDI tool
• Education and training tools in multiple formats
• Interoperable CDI tools
Metrics & Performance Management
Operational Sustainability
• Monitoring and reporting tools to track results in terms of case mix index (CMI), severity of illness (SOI), risk of mortality (ROM) and patient safety indicators (PSI)
Process Standardization
• Resilient governance structure
• Periodic external review and feedback
• Annual CDI Specialist and Coder training
• CDI performance metrics for physicians, CDI, coding and management
• Structured policies and procedures to standardize program requirements
• Specialty‐specific approach to physician training
Identifying Leading PracticesAn organization may define leading practices according to best practices established by American Health Information Management Association (AHIMA) and Association for Clinical Documentation Improvement Specialists (ACDIS)
Deloitte Advisory has developed a maturity model to help organizations determine the current state of the program compared to their desired future state.
I ‐ Beginning II ‐ Developing III ‐ Effective IV ‐ Advanced V ‐ Exceptional
The Maturity Model offers a structured mechanism to assess an organization’s performance against industry leading practices.
Modifying Existing ProgramsAssessment results should provide an indication of how mature your current CDI program is along with identifying opportunities with ICD-10 to advance your program further.
I - Beginning II - Developing III - Effective IV - Advanced V -Exceptional
• Little to no policies and procedures
• Decentralized operations
• Polices and procedures exist but not documented
• Limited Centralization
• Standardized, documented, applied and enforced polices and procedures
• Polices and procedures are routinely tested to confirm compliance
• Serve as a model for other organizations; shared service centersPr
oces
ses
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Common ICD-10 Impacts to CDI ProgramsICD-10 has created opportunities to better capture medical necessity, further identify severity of illness, and enhanced detail of conditions and procedures that will lead to better management of healthcare quality.
• Understanding key focus areas for diagnoses that require specific documentation in order to be coded
• Emphases on translation of clinical language to coding language to better capture full clinical picture of patients
• Clarifying that Documentation of suspected, possible and probable conditions when treatment and monitoring is occurring is appropriate
• Recognizing overall DRG shifts due to changes between the code sets
• Performing mortality reviews for cases that have APR-DRG SOI and ROM that is less than 4
• Identify top Medicare Severity Diagnosis Related Groups (MS-DRGs) and top surgeries and determine potential shifts and/or documentation challenges
Sample KPI Metrics for CDI Sustainability and Continuous Improvement
MCC/CC Capture tracking evaluates the frequency that a MCC/CC is captured on a bill
Alternate Principal Diagnosis Opportunities considers instances where an alternate principal diagnosis may be selected based on documentation in the chart and/or a generated query
Sign and Symptoms MS-DRG Frequency Analysis shows the trend of DRGs assigned to a sign and symptom/non-specific DRG
CMI Improvement by Service Line demonstrates the trending of CMI changes by Medical and Surgical Specialties post CDI education and revitalization.
Risk of Mortality and Severity of Illness Metrics displays trends of physician’s risk of mortality, severity of illness and GMLOS for informational and physician educational purposes
Coverage Analysis provides the percentage of Medical, Surgical, and Overall cases concurrently reviewed compared to the total Medicare population
Query Rate and Physician Response Rate provides a comparative analysis of the number of queries generated against the number of physician responses. Physician Agreement Rate should also be monitored against the number of Both retrospective and concurrent queries are recommended to be tracked
Actual Mortality Rates compared to Expected Mortality Rates by DRGs may be a useful metric to explore
CDI/Coder Mismatch will compare the frequency of mismatches against reconciliation when the CDI’s working DRG differs from the coder’s final DRG
Understanding Reimbursement SystemsClassification of inpatient stay resource intensity and illness severity is tied to reimbursement groupings. These groupings helps measure the case mix of an entity’s patient population.
MS-DRG
APR-DRG
• MS-DRGs are assigned to each inpatient stay.• MS-DRGs are divided into 25 major diagnostic categories (MDCs)• Select diagnosis codes are categorized as major
complications/comorbidities (MCCs) or complications/comorbidities (CCs)
• MS-DRGs have a weighted value depending on whether they are a single, pair or triplet combination inclusive of MCCs/CCs
• All Patient Refined Diagnosis Related Groups (APR-DRGs) focus on resource intensity
• There are 315 base APR-DRGs• There are two sets of subclasses, SOI and ROM that are added to the
base• APR-DRG is driven by principal diagnosis, procedures performed, all
• ICD-10 offers an opportunity to obtain better quality data due to the specificity offered within the code set
• A leading CDI program can leverage ICD-10 with a focus on documentation that should better reflect the severity of the patient substantiating resource use
• A leading CDI program should have a holistic approach that considers quality, complete documentation and reimbursement
• A leading CDI program increases MCC and CC capture, reflects the correct SOI/ROM values and potentially raises case mix
• Known shifts should be examined and monitored to determine their impact post ICD-10
Dr. Peggy Meli provides HIM operations, coding and clinical documentation reviews as well as Legal EHR designation, release of information operations, HIPAA compliance, ICD-10-CM/PCS coding, HIM IT coordination and healthcare risk management functions, training and educational solutions for healthcare facilities and physician practices. Peggy’s recent engagements at Deloitte Advisory include HIM Interim Management, ICD-10 implementation and charge capture review, Clinical Documentation Excellence and monitoring, ICD-10-CM/PCS Training and Implementation and HIM and coding review and process improvement. Additional engagements have included professional fee (E& M) coding, auditing, and physician compliance reviews.
Vickie is Deloitte Advisory’s national leader for the ICD-10 and Clinical Information Integrity and Maturity (CIIM) solutions, and co-leads the Clinical Documentation Excellence (CDE) practice. She has more than 27 years of experience in the healthcare industry in the areas of scheduling, patient access, medical necessity processing, utilization management, case management, medical records, patient accounting, billing compliance, charge integrity, chart-to-bill audits, CDE, charge description master (CDM) reviews and standardization, compliance risk assessments, compliance effectiveness reviews, compliance program development, internal control reviews, Recovery Audit Contractor (RAC) readiness, Medicare compliance, ICD-10, nursing, and supply chain.
MeShawn is a senior consultant in Deloitte’s Advisory health care practice with significant health information management experience focusing on finance, operations, and risk transformation in both the provider and payer environments. MeShawn possesses robust and diverse experience in end-to-end revenue cycle, data management governance, information governance, health system implementation, remediation, provider auditing, clinical documentation improvement, data analysis, ICD-9, ICD-10 and CPT coding and billing, payer system remediation, policy development, legal research, and technical solutions.
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