by Glenn Krauss, Regional Director of Enterprise Solutions, ZirMed
Current clinical documentation improvement (CDI) program initiatives have not evolved to meet the changing needs and requirements of medical record documentation under the transition to fee-for-value healthcare delivery models.
CDI was born as a revenue optimization strategy promoted by healthcare consulting companies, and gained prominence in the early 1980s with the advent of DRGs in 1982. These CDI-based revenue optimization programs scaled and became entrenched in many hospital facilities thanks to the demonstrated ability to generate additional net patient revenue. Recognizing the traction that the strategy was gaining in the market, consulting firms became very aggressive in promoting DRG optimization practices and techniques. This eventually caught the attention of CMS (known at the time as the Health Care Finance Administration, or HCFA) resulting in increased scrutiny of hospital efforts that were seen as possibly “gaming” the system in their quest to maximize DRG payments.
Witness the joint effort in 1998 by the Office of Investigation and the Department of Justice –the “Pneumonia Coding Project” that was announced as part of the 1998 OIG Work Plan. In their words:
- The Pneumonia DRG Upcoding Project was initiated to identify hospitals that falsify the diagnosis and diagnosis-related group [DRG] on claims from viral to bacterial pneumonia. The Office of Investigations is currently working with the Department of Justice to initiate a nationwide project in this area.
In 1999, the OIG in its Work Plan revised its description to note that the government would investigate pneumonia cases as both civil and criminal matters:
- This cooperative effort with the Department of Justice focuses on information that hospitals have up-coded the diagnosis-related group for pneumonia claims from viral to bacterial pneumonia. By doing this, the hospitals obtained almost $2,500 extra per claim in reimbursement. The OIG is looking at both civil and criminal implications.
This well-publicized focus on upcoding and DRG optimization caught the attention of hospital CFOs with the hugh paybacks required for “overcoding.”
The tail end of 1990s and early 2000s marked the true birth of clinical documentation improvement programs as they are known today. While CDI initiatives have evolved over time from a depth and breadth perspective to incorporate more sophisticated tracking systems, software to identify cases with the most opportunity for documentation improvement impacting revenue, automated query process, and employment of certified clinical documentation improvement specialists, in reality they have not changed in line with the requirement for robust, descriptive and complete documentation in support of accurate communication of patient care for all healthcare stakeholders.
Simply put, present CDI initiatives are missing a key element that is fundamental to successfully making the transition to value-based, cost-effective, and quality-driven alternate payment healthcare delivery models—namely, real and recognizable clinical documentation improvement.
CDI—a New Paradigm
CDI in its present form focuses primarily upon improving clinical documentation specificity and capture of additional diagnosis that translates into enhanced reimbursement for the hospital. Key performance indicators (KPIs) that are used to track overall successes of the program are based upon processes that ultimately generate revenue, certainly necessary in today’s environment of shrinking third-party payer revenue and margins—compounded by increasing business costs.
Increased revenue as an expected and achieved outcome for CDI initiatives is integral to revenue cycle goals and objectives, supporting and furthering the mission of serving the patient’s healthcare needs. Unfortunately, there is insufficient focus on CDI defining, promoting, and achieving best-practice standards of clinical documentation required for all the healthcare stakeholders including the patient. Accurate and complete documentation of diagnoses and procedure codes promotes accurate ICD-10 and DRG assignment with optimal net revenue. As I will discuss later in this article, what you should be measuring as a CDI KPI is net patient revenue versus gross patient revenue. Consistent increases in monthly case-mix achieved through CDI initiatives by definition does not equate to concomitant net patient revenue.
The new—and more impactful—paradigm of CDI may be defined as the completeness, consistency, organization and accuracy of the medical record, reflecting the physician’s clinical judgment and medical decision making. CDI supports positive outcomes in patient care, quality, cost, resource consumption, fee for value, patient reimbursement and revenue cycle processes. This new paradigm requires a wholesale shift in the mission, goals, and objectives of any CDI program. Goals, objectives, and mission of CDI should be to improve actual processes of clinical documentation, striving to achieve meaningful and lasting changes in physician behavioral patterns of clinical documentation that optimally reflect communication of patient care, regardless of stakeholder including third-party payers. By focusing on primary outcomes of reimbursement, we are overlooking the vitally important component of true documentation improvement. Enhanced reimbursement should be thought of and treated as a “byproduct” of solid documentation reflective of medical necessity for inpatient care, continued hospitalization stay, discharge stability, appropriate resource consumption and utilization review/management processes under Conditions of Participation, quality and efficiencies of care delivery, achieved outcomes and accurate clinical validation of all assigned ICD-10 codes and DRG assignment.
Proactive vs. Reactive
Transitioning from a reactive to a proactive CDI approach is the starting point to implementing a paradigm shift in overall CDI processes—one that engages physicians in true documentation improvement and aligns with revenue cycle and revenue integrity efforts. Present processes of combing through the medical record for purposes of identifying query opportunities for documentation improvement are rooted in reactivity in the sense that opportunities for necessary improvement of clinical context and content in support of establishment of medical necessity for hospitalization, regardless of inpatient or observation, are foregone.
A proactive approach to CDI consists of measureable improvement in actual physician documentation beginning in the Emergency Room, continuing in the History and Physical, logical and organized documentation of progress notes that serve to describe and show the clinical progress of the patient while hospitalized, and a discharge summary that actually best serves and meets the Joint Commission six elements required of a discharge summary.
One “byproduct” of this proactive approach to measureable CDI is accurate and complete coding, billing, and generation of “net patient revenue.”
Earlier I made reference to net patient revenue; I am convinced through first-hand experience in hospital denials and appeals that present CDI processes contribute to an overwhelming number of unnecessary, avoidable, self-inflicted denials through third-party payer enactment of cost containment strategies that include clinical validation of secondary diagnoses, retroactive determination of medical necessity for admission, alternate principal diagnosis selection, all allegedly based upon insufficiencies in documentation, inconsistencies in documentation, incongruences in documentation, insensible documentation, cut and paste progress notes without any indication of patient clinical stability and response to physician ordered plan of care, and discharge summaries devoid of pertinent requirements including inclusion of all relevant diagnoses associated with the stay.
If you factor into the equation of case-mix increases and increased revenue, costs to appeal these claims, time-value of money particularly with the ALJ third-level appeal process delay of 18 to 24 month, and denials ultimately not overturned on appeal, the net patient revenue generated by your CDI program may not be the return on investment you are calculating and reporting to the hospital’s finance committee and board of directors.
Getting Started—Optimizing CDI
There are several steps to building and expanding upon the current successes of your CDI program that will make an unequivocal impact on promoting and achieving best practice standards of clinical documentation serving all stakeholders.
The first—and most important—step to revisiting, revising, refocusing and re-branding CDI is updating the established mission, goals and objectives of your CDI program. If your program does not have any established mission, goals, and objectives—a not uncommon phenomenon—now is the time to establish them. Missions, goals, and objectives should embrace what is outlined above in the discussion of the new paradigm of CDI.
A suggested mission for the CDI program: promotion and achievement of effective clinical documentation that best serves to capture and reflect the right care at the right time for the right reason—in the right setting with the right documentation of clinical context, content, and of course the right diagnoses with clinical specificity. All of these elements serve as sound principles in effective communication of patient care effectively embracing and practically supporting concepts of medical necessity, reimbursement, outcomes, quality measures and alternate payment models such as bundled payments, shared savings programs and other risk sharing initiatives.
Second: establishment of infrastructure including current actual protocol processes of chart review; staff core competencies, skill sets, and knowledegebases; and realistic expectations of CDI staff. The latter must be revisited and revised as needed to reflect a commitment to achieving and attaining true clinical documentation improvement that furthers the hospital’s efforts and ability to successfully compete in the challenging healthcare environment through reporting of accurate and complete data utilized in fee-for-value.
Third: established key performance indicators should be updated and incorporate measures reflective of actual documentation improvement such as physician score cards used to judge the quality and effectiveness of their history & physical (H&P) and progress notes and discharge summaries as opposed to present KPIs such as number of queries generated, how many charts reviewed, how many queries responded to, and how many queries were for principal diagnosis or secondary diagnosis impacting reimbursement.
While these KPIs are vital to the effort of providing an objective assessment of current processes, they do little to measure the realized quality and effectiveness of documentation in support of revenue cycle and revenue integrity that will stand the test of time and net patient revenue.
Therefore, the ultimate (and ultimately most beneficial) starting point for a CDI transformation may be to visit your denials and appeals department and ascertain the magnitude and volume of denials and down-codes resulting in lower reimbursed DRGs from all third-party payers as well as CMS contractors—based on clinical validation, medical necessity, and alternate principal diagnosis selection.
I am confident that the insight gained from this analysis will spark organization-wide support to revisit, revise, reformulate, and re-brand your current CDI initiatives to more closely align with revenue cycle and fiscal operations.
And I am equally confident that the result of this investigation will be enhanced net patient revenue and overall strengthened financial performance.