What Can Clinical Documentation

Improvement Do For You?

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What Can Clinical What Can Clinical Documentation

Improvement Do For You?

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What Can Clinical Documentation

Improvement Do For You?

Presented By:yCheryl Ericson, RN, MS, CCDS, CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer, is

S k hAHIMA Approved ICD 10 CM/PCS Trainer, is the clinical documentation improvement (CDI) education director for HCPro, Inc., in Danvers, M Sh i f CDI d

Speaker Photo Here

Mass. She is a former CDI manager and managed utilization review and CMS quality measures at a large academic medical center. She has an extensive background that includes adult education, data analysis, knowledge of the healthcare revenue cycle and CMS guidelineshealthcare revenue cycle and CMS guidelines, and certification as an InterQual® instructor.

OIG Perspective on Hospital PoliciesO G e spect e o osp ta o c es

• With respect to reimbursement claims, a hospital’s ritten policies and proced res sho ld reflect andwritten policies and procedures should reflect and

reinforce current federal and state statutes and regulations regarding the submission of claims and M di t tMedicare cost reports.

• The policies must create a mechanism for the billing or reimbursement staff to communicate effectively and accurately with the clinical staff. Policies and procedures should: • Provide for proper and timely documentation of all p p y

physician and other professional services prior to billing to ensure that only accurate and properly documented services are billed;

OIG Perspective on Hospital Policiesp p

• Emphasize that claims should be submitted only when i t d t ti t th l i d lappropriate documentation supports the claims and only

when such documentation is maintained and available for audit and review; ;

• Indicate that the diagnosis and procedures reported on the reimbursement claim should be based on the medical record and other documentation, and that the documentation necessary for accurate code assignment should be available to coding staff; andto coding staff; and

• Provide that the compensation for billing department coders and billing consultants should not provide any financial incentive to improperly upcode claims.

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OIG Perspective on Hospital Policiesp p

• Policies and procedures concerning proper coding should reflect the current reimbursement principlesshould reflect the current reimbursement principles set forth in applicable regulations and should be developed in tandem with private payer and organizational standards.

• Particular attention should be paid to issues of medical necessity, appropriate diagnosis codes,medical necessity, appropriate diagnosis codes, DRG coding, individual Medicare Part B claims (including evaluation and management coding), and the use of patient discharge codes.the use of patient discharge codes.

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What Is Clinical Documentation?• Clinical documentation is the provider’s (e.g., physician,

advanced practice registered nurse or physicianadvanced practice registered nurse, or physician assistant) “recording” of any and all events related to a patient’s particular episode of care regardless of the setting (e g inpatient or outpatient)setting (e.g., inpatient or outpatient)– The Joint Commission and Centers for Medicare &

Medicaid Services (CMS) have guidelines on what elements must be recorded by the provider in the medical record, and some elements have associated timelines for completion of the documentation

• Documentation may be captured on paper, using an electronic format (EMR), or a combination of both known as a “hybrid” recordknown as a hybrid record

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What Is Coding?g

Coding is the translation of the “clinical language” within the health record (diagnoses andwithin the health record (diagnoses and procedures) into alpha-numeric codes, creating a common “language” for healthcare services g gthat is used for multiple purposes– The federal government determines which coding

language is used in what settinglanguage is used in what setting– Coders typically specialize by setting

• Inpatient services or outpatient services/professional iservices

Coding condenses potentially massive amounts of clinical information into a finite set of codes

Why Clinical Documentation Matters?y• Clinical documentation is the key driver for:

– Malpractice defensea p act ce de e se– Regulatory compliance– Accurate translation of quality of care

Accurate reflection of severity of illness (SOI)– Accurate reflection of severity of illness (SOI)– Justifying medical necessity of the inpatient admission– Accurate data and statistics for both hospital and

idprovider– Accurate and appropriate facility and provider

reimbursement– Potential defense against denials by RACs and other

third-party audits– Increasingly used to support the quality of healthcare

ithi th i tiwithin the organization

Medical Data• Every patient is unique; however, there are many

commonalities among healthcare consumers

• The International Statistical Classification of Diseases and Related Health Problems (ICD) is a medical classification system that provides codes to classify commonalities among those seeking healthcare

U d th ICD l ifi ti t h lth– Under the ICD classification system, every health condition (diagnosis) can be assigned a code

– There are strict rules regarding whose documentation g gcan be used for the purpose of assigning codes, when codes can be assigned, and how codes are sequencedsequenced

Source: World Health Organization (WHO)

Coding Clinical Documentationg• ICD-9-CM codes have been used for the purpose of hospital

reimbursement since 1983• The Health Insurance Portability and Accountability Act of 1996

(HIPAA) adopted a standard code set for different types of transactions

– ICD-9-CM Volumes 1 & 2 as distributed by the Department of Health and Human Services (HHS) was adopted for the reporting of the following conditions in all settings by all providers:• Diseases• Injuries• Impairments • Other health-related problems and their manifestations • Causes of injury, disease, impairment, or other health-related

problems

Coding Clinical Documentationg• ICD-9-CM Volume 3 as distributed by HHS was

adopted for the reporting of the following procedures oradopted for the reporting of the following procedures or other actions taken for diseases, injuries, and impairments on hospital inpatients reported by hospitals:hospitals: – Prevention – Diagnosis– Treatment

– Management

• Common Procedural Terminology (CPT) Fourth• Common Procedural Terminology (CPT), Fourth Edition, is used for physician services, therapies, radiological procedures, etc.—those services typically

id d i th t ti t ttiprovided in the outpatient setting

Whose Documentation Counts?• Inpatient healthcare data and reimbursement is obtained

from ICD-9-CM diagnosis and procedure codes, which are gbased ONLY on the documentation of those licensed independent providers who give direct care– Pathology, radiology, nursing, and ancillary staffPathology, radiology, nursing, and ancillary staff

documentation can provide “clues” to incomplete, vague, and missing diagnoses, but ICD-9-CM codes cannot be assigned based on these types ofcannot be assigned based on these types of documentation

– Professional reimbursement uses a different set of codes (CPT 4) and rules for reimbursement ascodes (CPT-4) and rules for reimbursement as mandated through HIPAA legislation, so providers are often unfamiliar with the rules associated with inpatient reimbursementreimbursement

Typical Translation/Coding Processyp g

Provider documentation

ICD-9-CM codes

(sequencing = principal diagnosis selection)

Grouping of ICD-9-CM codes

(APR-DRGs, DRGs, MS-DRGs)( )

Claims submission

Hospital Inpatient Codingp p g• Typically inpatient coding occurs post-discharge

– Provider charges are often submitted faster than hospital charges

• Problems arise when the hospital billing does not match provider billing

• Coding often occurs without the discharge summary• Coding often occurs without the discharge summary

– Providers have up to 30 days to complete

• There can be discrepancies between the submitted bill and discharge summary when coding occurs without it

– When the discharge summary is present, coders typically review the record “backwards” starting with the discharge summarythe record backwards starting with the discharge summary

• The record needs to be coded and finalized within four to six days of discharge to “drop” the bill/submit the claim

– The revenue cycle monitors the length of time it takes to code and submit a claim, which is referred to as “bill hold”

Coding Professionalsg• Coding is a very exact discipline where the clinical

documentation must exactly match the codingdocumentation must exactly match the coding terminology for a code to be assigned; however, there is much variation among coders regarding when the documentation is sufficient to assign awhen the documentation is sufficient to assign a code, which code to assign, and how to sequence the codes

• Coders cannot make assumptions or interpret the provider’s intention

• Coders have rigorous productivity metrics• Coders have rigorous productivity metrics • Inpatient hospital coders often have little or no

interaction with the medical staff– Many work remotely

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Clinical Documentation Improvementp

• The profession of clinical documentation improvement began in the 1990s as an outgrowth of codingbegan in the 1990s as an outgrowth of coding– A nationally recognized CDI credential was created by

ACDIS with first designations in May 2009

• The official coding guidelines and Cooperative Party guidance applies to CDI professionals regardless of the credentials of the CDI professionalscredentials of the CDI professionals

• The American Health Information Management Association (AHIMA) is a coding authority

• The Association of Clinical Documentation Improvement Specialists (ACDIS), an HCPro association, is a leading authority for CDI (not specifically coding)authority for CDI (not specifically coding)

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Clinical Documentation Improvement

• Although coders have traditionally queried providers that is asked them for clarificationproviders—that is, asked them for clarification regarding their documentation for the purpose of accurately coding the health record—increasing y g gmedical complexity and changing healthcare reimbursement methodology supported the growth of this ne CDI professionthis new CDI profession

• The strength of CDI is concurrent review while the patient is in the hospital rather than followingpatient is in the hospital rather than following discharge during the coding process– Increases physician satisfaction and participation to

address issues while still providing care

The Role of CDIGeneral mission:

– Facilitate the creation of a health record that accurately represents the acuity of the patient's illness and the hospital resources used to treat the

ti t b i id d t ti bpatient by ensuring provider documentation can be “matched” with ICD-9-CM codes

Work collaboratively with the medical staff and– Work collaboratively with the medical staff and coding department to translate provider documentation into diagnostic terms that can bedocumentation into diagnostic terms that can be captured by ICD-9-CM codes while the patient is receiving inpatient hospital treatment (concurrent g p p (review)

The Role of CDIS

• Typically CDS departments are implemented under the direction of the chief financial officerunder the direction of the chief financial officer (CFO) for the purpose of revenue enhancement through the capture of diagnoses classified by CMS called complicating conditions (CC) or major complicating conditions (MCC)

CDIS i th di l d t id tif– CDISs review the medical record to identify missing, vague, and incomplete diagnoses that can impact reimbursementcan impact reimbursement

– CDI must balance the goal of financial returns with ethical practices using industry standards

CDI Reviews• While the health record of all episodes of care must

be translated into coded data by coders/coding for y gclaims submission, CDI reviews are typically focused on short-term acute inpatient care paid under Medicare reimbursement methodology

• Other payer types are often reviewed depending on the mission of the CDI department, the goals of the organization, staffing, and the skill level of the staff

– All DRG payers

– Medicaid patients

– Pediatric populations

Patient Populations Reviewed by CDIp y• Almost all CDI departments review Medicare patients

Traditionall foc sed on the ad lt pop lation e cl ding– Traditionally focused on the adult population, excluding obstetrics

– Reimbursement based on Medicare severity diagnostic-Reimbursement based on Medicare severity diagnosticrelated groups (MS-DRG), except Maryland

• Another common grouper is the All Patient Refined (APR)-DRG classification system proprietary to 3M, which uses the same elements as those used by the MS-DRG classification system (e g principal diagnosis secondaryclassification system (e.g., principal diagnosis, secondary diagnosis, and valid surgical procedure)

– The type of payer being reviewed will determine the frequency and number of follow-up reviews

The Role of CDISDue to continued government scrutiny, many CDI departments have shifted their focus from revenue enhancement to quality improvement

– A new focus of improving organizational and professional quality metrics

• Mortality index, CMS metrics, etc.

Thi b d f l lt i i d– This broader focus can also result in improved reimbursement as many of the “important” diagnoses impact both reimbursement and qualitydiagnoses impact both reimbursement and quality

– Organizations may need to review current CDI responsibilities as they may not be sustainableresponsibilities as they may not be sustainable during the transition to ICD-10-CM/PCS

The CDI Professional

Health information management (HIM) professionals

– Coders

– Registered Health Information Technician (RHIT)

– Registered Health Information Administrator (RHIA)

– Registered nurses

• Majority of professionals in this position

– Providers (MDs, physician assistants, etc.)

• Physician champions or paid physician advisor

• Foreign-trained providers not licensed to practice in the United States

Nurses Staffing CDIPositive attributes:• Interacting with providersInteracting with providers

– Able to speak the same language as providers– Comfort providing guidance to providers

• Interpreting clinical indicators– Ability to prioritize healthcare data

Understanding of anatomy physiology and disease– Understanding of anatomy, physiology, and disease processes

– Familiarity with abnormal diagnostics and diagnosis hpathways

• Knowledge of the health record• Relationship with other healthcare providersRelationship with other healthcare providers

– Floor nursing staff, case management, etc.

Nurses Staffing CDIgNegative attributes:

Lack of understanding/training in coding guidelines and• Lack of understanding/training in coding guidelines and guidance

– The goal is not for CDI staff to be coders as the coders willThe goal is not for CDI staff to be coders as the coders will still assign the billed codes

• Tendency to make assumptions or “interpret” the provider’s intention

• Unfamiliarity with hospital reimbursement methodology

– Inpatient hospital services are paid under the inpatient prospective payment system (IPPS) that is based on Medicare severity diagnostic-related groups (MS-DRG) for ed ca e se e y d ag os c e a ed g oups ( S G) omost states

Short-Stay Acute Care FacilitiesShort Stay Acute Care Facilities

• Most healthcare providers are dependent on CMS payments for providing healthcare to their covered populations

The power of CMS is such that some Medicare– The power of CMS is such that some Medicare rules apply to all patients, regardless of payer source, to avoid discrimination of CMS ,beneficiaries

• Short-term acute care facilities, referred to as “hospitals,” which accept CMS beneficiaries, agree to inpatient care reimbursement under the inpatient prospective payment system (IPPS)prospective payment system (IPPS)

Inpatient Prospective Payment SystemSystem

• Short-term acute care hospital payment rate is established by the diagnostic-related group (DRG), which is the same value for all hospitals, defined by the relative weight (RW) of the DRG or Medicare severity diagnostic-related group y g g p(MS-DRG)

– Each organization has its own operational (base) rate th t i d t d ll b d i t f i blthat is updated annually based on a variety of variables

• The payment rate is “fixed” based on the principal diagnosis, the presence of any diagnoses Medicarediagnosis, the presence of any diagnoses Medicare defined by ICD-9-CM code as “complicating” conditions (CC) or “major complicating” conditions (MCC), and, if applicable the presence of reimbursable proceduresapplicable, the presence of reimbursable procedures

Examples of CCsp• Bacteremia• Hemiparesisp• Hematemesis• Acute esophagitis

A t l f il• Acute renal failure• Urinary tract infection• Chronic systolic heart failureChronic systolic heart failure• Acute exacerbation of COPD• Senile dementia with agitation• Anemia due to acute blood loss• Morbid obesity or obesity with BMI > 39• Chronic kidney disease (CKD) stages IV or V• Chronic kidney disease (CKD) stages IV or V

Examples of MCCsp• HIV

• Coma

• Cerebral edema

• Acute cerebral infarct

• End-stage renal failure

• Pneumonia (most types)

• Acute respiratory failure• Acute respiratory failure

• Esophageal varices with bleeding

• Acute on chronic systolic heart failure

• Stage III or IV decubitus ulcer (when POA)

• Acute renal failure due to/with ATN, medullary or cortical necrosisnecrosis

Inpatient Prospective Payment S stemSystem• The MS-DRG payment covers all services rendered

b th h it l d i i ti t t dl fby the hospital during an inpatient stay regardless of the length of stay* (LOS) – * Unless an outlier Unless an outlier

• Sequencing of diagnosis codes into the principal diagnosis and secondary diagnoses greatly impacts MS DRG i tMS-DRG assignment – Coders and CDSs must understand what qualifies

as principal and secondary diagnosesp p y g• Software programs called “groupers” are often used

to assign diagnosis and procedure codes as well as sequence the codes into an MS DRGsequence the codes into an MS-DRG

How Do Hospitals Get Reimbursed? p

Each MS-DRG has a uniqueEach MS DRG has a unique RELATIVE WEIGHT (RW)

XXThe hospital’s BASE RATE

=Hospital payment ($)

Know your facility’s base rate$5,209 national average$5,209 national average

Payment Calculationy

0.7037X $5,209$3 665 57$3,665.57

Regardless of the cost of services provided to a patient if th f ll i t MS DRG 296 th h it l ill bif they fall into MS-DRG 296, the hospital will be reimbursed $3,665

Impact of a CCp

A patient admitted with pneumonia also has a diagnosis of CHFof CHF

– The term CHF has an ICD-9-CM code, but it has no value as a CC or MCC

• DRG 195 Simple Pneumonia = $3,665

– Additional specificity of the type of CHF as systolic or diastolic can add a CC thereby increasing thediastolic can add a CC, thereby increasing the reimbursement value

• DRG 194 Simple Pneumonia w/CC (RW = 1.0026) = $5,222

A i i i b t f $1 557– An increase in reimbursement of $1,557

– Translated into 100 cases in a year, that is an increase in reimbursement of $155,700 ,

Impact of an MCCp

A patient admitted with pneumonia also has a diagnosis of CHFof CHF

– The term CHF has an ICD-9-CM code, but it has no value as a CC or MCC

DRG 195 Si l P i $3 665• DRG 195 Simple Pneumonia = $3,665– Additional specificity of the type of CHF as systolic or

diastolic can add a CC, but if that patient also has an b ti f th i t li h t f il th t ddexacerbation of their systolic heart failure, that adds an

MCC• DRG 193 Simple Pneumonia w/MCC (RW = 1.4948) =

$7 786$7,786– An increase in reimbursement of $4,121 – Translated into 25 cases in a year, that is an increase

in reimbursement of $103 025in reimbursement of $103,025

What Is Clinical Documentation Improvement (CDI)?Improvement (CDI)?

CDI is a team approach to improving concurrent (while the ti t i i i ) d t ti tipatient is receiving care) documentation practices

through ongoing education and clarification of clinical documentation that can’t be matched with an ICD-9-CM

dcode.The goals of CDI are to facilitate clear, concise, clinically

accurate information in the medical record through the id tifi ti f i l t d/ i iidentification of incomplete, vague, and/or missing diagnoses allowing capture of all applicable diagnoses by ICD-9-CM code to reflect:– Accurate reimbursement – Quality of care/services provided– Patient severity of illness/risk of mortality

Appropriate hospital and physician profiles– Appropriate hospital and physician profiles

Clinical Documentation ImprovementClinical Documentation Improvement

• The August 2007 Federal Register directs hospitals to make attempts to improve all aspects of clinical documentation– “We do not believe there is anything inappropriate,

unethical or otherwise wrong with hospitals taking f ll d t f di t iti t i ifull advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record ”documentation in the medical record.

Source: CMS 2008 IPPS Final Rule:

http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf, p. 208.

Revised Workflow With CDIProvider clinical documentation

CDI iCDI review

• Obtains concurrent clarification as needed from providers regarding incomplete, vague, and missing diagnoses

• Offers feedback/clinical perspective to coding on the selection and identification of the principal and secondary diagnoses

• May include assignment of working DRGs

Coding

• Applies final ICD-9-CM codespp• “Groups” the codes to finalize DRG assignment/verify CDI working

DRG• Verifies diagnosis sequencing though knowledge of coding g q g g g g

guidelines and Coding Clinic guidance in establishing the final DRG assignment

Collaborative Record Review: A Full Circle ApproachA Full-Circle ApproachAHIMA Guidance for CDI Programs 2010• A feature of the CDI process is conducting

concurrent reviews of the health record. Depending on the relationship between the CDI program and theon the relationship between the CDI program and the HIM department, the CDI staff may hand off records to the HIM department following discharge or they may continue to follow up on open questions beforemay continue to follow up on open questions before the final billing process.

• Some CDI programs conduct retrospective reviews, while others leave this to the HIM department. Regardless of when the reviews are conducted, the goal is to clarify ambiguous, conflicting, or incompletegoal is to clarify ambiguous, conflicting, or incomplete documentation.

Clinical Documentation Specialistp

• One of the core job requirements of a CDS is to be bl t l t li i l i di t ithi th h lthable to locate clinical indicators within the health

record as documented by any member of the healthcare team (coders often focus only on treatinghealthcare team (coders often focus only on treating provider documentation) and to determine whether these clinical indicators support the possibility of anthese clinical indicators support the possibility of an incomplete, missing, or vague diagnosis that meets the definition of a principal or secondary diagnosis

• Depending on the focus of the CDI department, knowledge of MS-DRG distribution can also assist with prioritizing query efforts

CDI Professionals

• Stronger clinical skills often translate into increased identification of vague, incomplete, and/or missing documentation in the medical record that can lead to the capture of a CC or MCC

– The CDI profession is predominantly staffed by nurses

• CDSs must be able to articulate the clinical indicators into terms that capture the intent of the provider and can be captured by ICD-9-CM code

QueryingQ y g

• When clinical indicators suggest a possible CC or MCC that can’t currently be captured by ICD-9-CM code as documented, they work with the provider to

h th th t d t ti i tsee whether the current documentation is accurate or whether additional documentation that allows a more specific code is necessaryspecific code is necessary

• Neither CDSs nor coders can tell a provider what to document for the purpose of impacting coded datadocument for the purpose of impacting coded data

– The provider must have the option to disregard or disagree with the request for additional documentationdisagree with the request for additional documentation

Provider Communication

• AHIMA Guidance for CDI Programs 2010• AHIMA Guidance for CDI Programs 2010

– “Another key element of the CDI process is id i ti P i t CDIprovider communication. Prior to CDI programs,

the query process was the responsibility of HIM professionals; however depending on theprofessionals; however, depending on the staffing model, the CDI professional either shares the query role with HIM professionals orshares the query role with HIM professionals or assumes complete responsibility of the process.”

QueryingQ y g

• As previously mentioned, many CDI departments i ibilit f i ithiare assuming responsibility for querying within an

organization so the record is complete and accurate prior to coding to minimize delays in the coding and p g y gbilling of the claim, thereby reducing the number of days claims remain on bill hold

• Although the professional background of CDSs vary, the CDS must possess excellent interpersonal communication skills critical thinking skills and acommunication skills, critical thinking skills, and a strong understanding of disease processes with their associated clinical indicators

Hot Topics in CDIp• ICD-10-CM/PCS• CMS quality metricsCMS quality metrics

– Hospital value-based purchasing

• Government scrutiny – “Upcoding”– Diagnoses without supporting clinical evidence

• Medicaid audits• Medicaid audits– These will be state specific

• Outpatient services– Emergency department setting– Ambulatory surgery setting

• Children’s hospital/pediatric cases• Children s hospital/pediatric cases

Summaryy

• The clinical documentation specialist is a professional who combines clinical expertise with understanding of medicalcombines clinical expertise with understanding of medical coding to support the provider so the health record accurately represents the severity of the patient’s episode of care and use of hospital resourcescare and use of hospital resources

• CDI departments have positively impacted organizations in regards to both financial metrics and quality of care metrics that are based on coded data

• The role of the CDS continues to expand as the benefits of accurate provider documentation can impact many moreaccurate provider documentation can impact many more facets of care, including outpatient services and organizations reimbursed by other prospective payment

tsystems

Questions & Answers49

Cheryl Ericson, RN, MS, CCDS,CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer HCPro, Inc. Danvers, Mass.

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