Associate Director's Note: Value based CDI: Keep up with changing initiatives

Quality. Mortality. Advanced CDI. Pay-for-performance. Value Based Purchasing (VBP). Last week’s ACDIS Quarterly Membership Conference Call touched on a number of these topics.

Many CDI professionals feel enough pressure keeping up with the daily activities of regular record reviews, capturing principal and secondary diagnoses, providing physician education, composing compliant queries, and preparing for ICD-10-CM/PCS. Yet, the drum beat that is capturing quality and complete documentation continues to sound ever louder as CMS’ strides to tie reimbursement to such measures lengthens.

In January, the Department of Health and Human Services Secretary Sylvia Burwell announced the agency’s intention to ramp up its VBP reimbursement methodology—from 20% to 30% by the end of 2016, and to 50% by the end of 2018. Burwell additionally called for the percentage of Medicare payments linked to overall quality and value to rise to 85% by 2016, and 90% by 2018.

Meanwhile, a collection of reports from Kaiser Health News illustrate the cumulative effect of these various incentives and penalties on facilities—essentially demonstrating that, while a facility may perform well on one incentive, it frequently falls flat on another, making it difficult to breakeven financially.

CDI specialists and managers need to use these recent news items to help them make the case for program advancement to administration, according to Dee Banet, RN, BSN, CCDS, CDIP, director of CDI at Norton Healthcare in Louisville, Kentucky, who wrote about how to change the traditional “CDI for reimbursement” conversation in the January edition of the CDI Journal.

“A CDI program that broadens its focus to include quality indicators can still be described as a program with a financial focus. VBP puts at risk future reimbursement for an organization’s entire patient population if outcomes are not met. This at-risk reimbursement is the indirect financial impact a CDI program can bring to the table by focusing on and improving documentation that drives the quality indicators,” Banet wrote.

 The ripples from VBP and the government’s healthcare reform focus on payment for care quality touch all manner of healthcare providers—including physician practices and outpatients services, ACDIS Advisory Board member James P. Fee, MD, CCS, CCDS, Vice President of Huff DRG Review told last week’s Quarterly Conference Call participants.

“We are moving to clinical integration and partnerships, physicians and CDI staff are increasingly involved in capturing true severity and complexity of patients across the continuum of care,” said Fee. “We need to maintain our awareness of these new concerns and look to obtain new levels of expertise and physician involvement if we (and our facilities) are going to be successful.”

“This is something we should embrace and be excited about,” Laurie Prescott, RN, CCDS, CDI Boot Camp Instructor for HCPro in Danvers, Massachusetts, said during the call.

“Everyone wants quality for their dollar and this helps get us there,” said Prescott. “These initiatives are going to help us bring in physician involvement because of the quality focus and broad scope of expectations.

Indeed, physicians have their own set of CMS reimbursement tied to value under the Medicare Physician Fee Schedule (MPFS) called the Value-Based Payment Modifier. (CMS released an easy-to-follow Fact Sheet on the matter just this week.) Similarly, the methodology on the inpatient hospital payment side means physicians face a payment adjustment for the 2015calendar year, with ranges from a downward adjustment of negative 1% (for low quality/high cost care) to an upward adjustment of positive 2.X% (for low cost/high quality care).

While the drum sounds louder and louder, it needn’t create an ominous rhythm. With a little self-study regarding the various payment focus areas, CDI can incorporate such measures into their existing reviews and, as Banet suggests, use the information to help shift CDI focus and gain support for program expansion from both physicians and administrators.