Associate Director's Note: Time to sit down and have a talk

We don’t like to talk about it much. In fact, although it remains one of the principal reasons facilities start a CDI program, we steer clear of open discussion on the topic. It’s like that family rule about Thanksgiving Day conversations: Just as you don’t talk about politics or religion at the dinner table, CDI and coding staff shouldn’t discuss their efforts’ effect on healthcare reimbursement.

As the Association of Clinical Documentation Improvement Specialists, we consistently offer advice, expert insight, and even industry guidelines instructing CDI specialists to veer from headlong fiscal discussions. 

And with good reason. A physician query that contains multiple choice responses with related codes and relative weight (i.e., reimbursement level) clearly indicates that if physician chooses answer X over answer Y, the facility stands to make more money.

Over time, physicians automatically start choosing the higher-weighted response. Over time, physicians start to view CDI program efforts as a means to principally financial ends. Over time, the facility’s patients all seem to suffer from similar diagnoses even if that diagnosis doesn’t best represent the patient’s condition. Over time, the patients’ records no longer truly reflect the actual conditions being treated, but those which earn the hospital the most money—and that constitutes fraud.

And yet…

CDI programs (directors, managers, staff, etc.) do the community a disservice by stifling such conversations. Last summer, 1,660 respondents to an ACDIS website poll underestimated their effect on the revenue cycle.

Understanding the proverbial money trail helps CDI programs prove their return-on-investment not only to the hospital administration but, if done appropriately, to the larger physician staff whose buy-in they need to be successful.

American culture demands the highest quality items at the lowest possible cost, ACDIS Advisory Board member Fran Jurcak, RN, MSN, CCDS, senior director in CDI practice at Huron Healthcare in Chicago, told the CDI Journal previously.

And that’s precisely where healthcare reimbursement trends have been falling over the past few years as well. So CDI programs must prove their overall fiscal value and their overall impact on quality scores/metrics that are driving healthcare reform.

More than 40 roundtable attendees listed CDI as their principal solution to “a copious number of concerns” related to value-based reimbursement methods during a Healthcare Financial Management Association (HFMA) conference this week, HealthLeaders Media reported.

“CDI is a key element of optimizing the revenue cycle function on several fronts,” George Semko, administrative director of revenue cycle at Fishersville, Virginia-based Augusta Health said in the article. Semko noted the importance of “opening up lines of communication between the clinicians and the revenue cycle administrators.”

Patient-specific financial outcomes should be off-limits during CDI/physician queries and one-on-one discussions. However, the overall financial effect of physicians’ query responses (unanswered, agree, disagree, etc.) can highlight the importance of documentation improvement and illuminate opportunities for physician staff.

Finally, CDI programs do need to return to the “quality documentation equals healthcare quality” theme, as former ACDIS Advisory Board member Dee Banet, RN, BSN, CCDS, CDIP, points out in her January 2015 CDI Journal article “Financially focused CDI programs: Past or future?”

“As our payers move from pay-for-service to pay-for-performance, we must shift our focus to align with these changes,” Banet writes.

Effective in fiscal year 2015, facilities will receive either cuts or increases to their DRG base payments of 1.5% due to their performance on a number of quality measures.

So, yes, it’s like Semko says, CDI is the key element in protecting the healthcare revenue stream on a variety of fronts. But really, we (those working in the front lines of the CDI profession) have been saying that all along—when the quality of the medical record documentation improves everything else does, too, including quality measures and reimbursement.

So why not talk about it