2/18/2019 1 The Importance of CDI: Inpatient and Outpatient Michele Hand, Senior Clinical and HIM Consultant CDI • A collaborative process between coding, CDI professionals and providers to ensure that documentation accurately reflects the condition and acuity of the patient during the episode of care. • CDI reconciles inconsistent, incomplete, and conflicting documentation prior to the final coding 2
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The Importance of CDI - Arkansas HFMA · The Importance of CDI: Inpatient and Outpatient Michele Hand, Senior Clinical and HIM Consultant CDI • A collaborative process between coding,
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2/18/2019
1
The Importance of CDI:Inpatient and Outpatient
Michele Hand, Senior Clinical and HIM Consultant
CDI
• A collaborative process between coding, CDI professionals and
providers to ensure that documentation accurately reflects the condition
and acuity of the patient during the episode of care.
• CDI reconciles inconsistent, incomplete, and conflicting documentation
prior to the final coding
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Characteristics of Good, Quality Documentation
• Complete
– Complete clinical picture of the patient encounter
– Includes chief complaint; physician orders and reason for the
orders; diagnostic test results; procedure, therapy and nursing
notes; physician and consultant notes
• Reliable
– Content is trustworthy and safe and everyone reading the record
has the same understanding
• Precise
– Accurate and well defined
– Detail supports clinical picture from diagnostic and treatment
positions.
– Clinical details include vitals, test results and other clinical
indicators needed for the diagnostic process
Characteristics of Good, Quality Documentation
• Consistent
– No contradictory statements from providers
– If diagnosis changes, indicate reasons for further specificity or new
diagnosis.
• Legible
– Documentation must be able to be understood by everyone
reviewing it.
– Illegible documentation compromises the quality of documentation
• Clear
– Comprehensible and distinct
– Vague documentation can be ambiguous and unclear
• Timely
– Available when it is needed for patient care delivery.
– Cannot be corrected after the fact
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Complete Medical Record Entries
• Support the diagnosis/condition
• Justify the care, treatment, and services
• Document the course and results of care, treatment, and services; and
promote continuity of care among providers
Evolution of Clinical Documentation Improvement
• Initial endeavors started in the inpatient setting
– These are still important, but with time, providers need less
assistance
– Capture comorbid conditions and major comorbid conditions
• MS-DRG Assignment
– Assign APR-DRGs which use SOI (severity of illness) and ROM
(risk of mortality)
– Document Present on Admission
– Ensure patients meet medical necessity and are placed in the
correct level of care
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DRG and Comorbid Condition Example
Scope of Focus is Expanding
• Inpatient Setting
– Hospital Value Based Purchasing
• Quality
• PSIs
– Clinical Validation
– Hierarchical Condition Category (HCC)
– Denial Management
• Outpatient Setting
– Hierarchical Condition Category (HCC) and Risk Adjustment
Scores
– E/M Levels
– Medical Necessity
– Denial Management
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Inpatient CDI
Hospital Value Based Purchasing
• Designed to improve the quality, efficiency, and safety of care during
acute care inpatient stays and to improve experience of care during
hospital stays
– Reduce or eliminate adverse events
– Adopt evidence-based standards and protocols that improve patient
outcomes
– Improve the transparency of care quality
– Improve patient experience
– Recognize hospitals providing high quality of care at lower costs
based on achievement and improvement
• Performance period for 2019 was 2017
• 2019 performance will affect future reporting
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2019 Performance Based on Four Quality Domains
CMS: Understanding the Fiscal Year 2019 Hospital Value-Based Purchasing Program, July 2018
Four Quality Domains
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CMS PSI 90 Measures
Hospital Acquired Conditions Reduction Program
• Hospitals that are not above the 75th percentile of reporting hospitals will
receive a 1% reduction in payment of claims for FY 2019
• Retrospective, so documentation this year will be used for future
reporting
• These are publicly reported on Hospital Compare
• 2 Domains are reviewed
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Hospital Acquired Conditions Reduction Program
– Domain 1: 10 PSI 90 Measures
• Reporting period 10/1/15 – 6/30/17
• 15% of total score
– Domain 2: 5 Healthcare Associated Infections
• Reporting period 1/1/16 – 12/31/17
• 85% of total score
Hospital Readmission Reduction Program
• Readmission is defined as an admission within 30 days of a discharge
from the same or another IPPS acute care hospital.
• Looks at 3 years of discharge data
– 2019 looks at 7/1/14 – 6/30/17
• Do not know what future readmissions will be measured, so
documentation must be complete for all conditions treated.
• Must have 25 discharges for the condition that is being measured
• Compared with hospitals in same “Peer Group”
• Reported on Hospital Compare
• This is a penalty program
– Maximum penalties of 3% reduction in payment
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Hospital Readmission Reduction Program
• Looks at readmissions in 6 areas
– Acute Myocardial Infarction (AMI)
– Chronic Obstructive Pulmonary Disease (COPD)
– Heart Failure (HF)
– Pneumonia
– Coronary Artery Bypass Graft (CABG) Surgery
– Elective Primary Total Hip Arthroplasty and/or Total Knee
Arthroplasty (THA/TKA)
Clinical Validation
• Diagnoses documented in a patient's record must be substantiated by
clinical criteria generally accepted by the medical community
– Professional guidelines and consensus
– Evidence-based sources
• Should not have conflicting documentation between providers
• Focus of RAC and MIC Audits
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Clinical Validation
• Separate function from DRG Validation
• Separate function from routine coding process
• Facilities should have a process in place to validate clinical conditions
prior to completing the coding process
• Ensure not only accurate coding but to also reflect the accurate clinical
scenario
• Examples
– Pneumonia with a negative chest x-ray
– Acute respiratory failure with normal ABGs
– Severe malnutrition with a normal BMI
Clinical Validation Queries
• Is there conflicting documentation between providers?
• Would the provider come to the same conclusion based on the same
information?
• Is the diagnosis a reasonable conclusion based on the totality of the
health record?
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Clinical Validation for Difficult Diagnoses
• Create list of vulnerable diagnoses and agree on standard clinical
indicators for diagnosis
– Criteria should be provider driven
– Many diagnoses lack a standardized definition
– Evidence based
– Goal to promote consistency in diagnoses criteria
– Internal policy helps with RAC Audits
• Providers should always be ready to defend their diagnoses to auditors
• Collaborative CDI/coding/provider meetings
• Second-level reviews to validate an accurate and complete clinical
picture
Outpatient CDI
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Outpatient CDI
• Multiple Outpatient Settings
– Hospital
• Emergency departments
• Infusion departments
• Other outpatient services
– Physician offices
– Outpatient surgery centers
Outpatient CDI Focus
• Select a focus of high volume, high risk review areas
– Risk - Reimbursement and Quality Score Impact
– Volume -Top 10 diagnoses and procedures
– Review
• Claims data
• Frequency of claims edits
• Coding audit report
• Denial information
• Chargemaster
• E and M
• HCCs and Risk Adjustment Scores
– Look at specific payors
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Chargemaster Review
• Prevents
– Overpayment or overcharging
– Underpayment or undercharging
– Claims rejections
– Fines
– Penalties
• Looks at supplies, devices, medical services and procedures
• Implement changes
• Schedule regular reviews, at least annually
Chargemaster Review Process
• Assemble team
– CFO or finance department billing department representative
– Representative from each charging department
– Coding representatives
– information systems department representative
• Run reports of chargemaster for review
• Chargemaster should be Current, Comprehensive, Compliant
• Research chargemaster issues, including new codes
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Evaluate and Manage
• May 2014 Report from OIG
– Over 40% of claims for E&M services were incorrectly coded and/or
lacking documentation
– E&M Claims are 50% more likely to be paid in error than any other
Part B services
– Target for audit
– Providers who bill for high level E&M codes are heavily scrutinized
by OIG and CMS Contractors
– Large percentages of errors identified were downcoding
Level of E/M Service Performed
• Selection of code depends on
– Patient type
– Setting of service
– Level of E/M services performed
• Code sets organized into various categories and levels.
– More complex the visit, the higher the level of code
• Provider is responsible the select a code that reflects the services
furnished.
• 3 key components
– History
– Examination
– Medical Decision making
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Medical Necessity
• Health care services or procedures that are necessary for the purpose
of preventing, diagnosing or treating an illness, injury, disease or its
symptoms in a manner that is
– In accordance with generally accepted standards
– Clinically appropriate in terms of type, frequency, extent, site
– Not primarily for the economic benefit of the health plans, providers
or beneficiaries
• Understand NCDs and LCDs and benefits of specific plans
Hierarchical Condition Categories
• Chronic health conditions or diagnoses that require a higher level of
resources to treat
– Given a weight
• Used by payors, including Medicare and Medicaid, to predict future
healthcare costs for beneficiaries
• CMS has 83 HCC categories for 2019 and HHS has more, with close to
10,000 ICD-10 codes within the categories
• Must be documented and coded every year
• Used to predict the healthcare costs of beneficiaries
– RAF Score
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Hierarchical Condition Categories
• Review Quality Measure, MACRA and MIPS reports to see gaps