Guest Post: Expanding CDI focus beyond MS-DRG capture

by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS

The recent ACDIS Radio titled “Resolving Coder and CDI Clashes”presented on February 4 was another thought provocative discussion on an important area for most CDI programs.

Allow me to share my own personal thoughts and comments on the concept of MS-DRG congruence tracking in the hopes of provoking beginning a dialogue on the value even incorporating the MS-DRG tracking into a CDI program. Let’s start by defining the core elements of an effective CDI program.

An effective CDI program strives to demonstrate, collaborate, promote, and continually improve clinical documentation. Its purpose is to ensure that medical record documentation is effective, efficient, concise, coherent, complete, and accurate, and that it supports good patient care and captures quality outcomes.

An integral part of CDI specialists’ day-to-day duties and responsibilities is working closely with physicians and other allied health professionals to make a compelling case for best practice strategies of clinical documentation; documentation which clearly captures the physicians’ effective care choices through their:

• clinical judgment
• medical decision making
• thought processes
• analytical skills
• problem solving ability

These elements serve as the fundamental basis for Medicare’s recently reinforced commitment to transitioning away from volume-based, fee-for-service, healthcare reimbursement to one which embraces the “triple aim.” The “triple aim” is a framework developed by the Institute of Healthcare Improvement which calls for simultaneously improving an individual’s experience of care, improving the health of populations, and reducing the per capita costs of the care provided.

Medicare’s goal in this value-based, cost-effective, quality-focus approach to the delivery and payment was summarized best in a January 26, 2015 release titled “Better Care, Smarter Spending, Healthier People: Improving Our Health Care Delivery System.”

Consider the following statements from this fact sheet:

• Improving the quality and affordability of care received by Americans is, alongside increasing access to it, a core pillar of the Affordable Care Act. The Administration is working to ensure that:
  
  • Americans receive better care
  • Our health care dollars are spent more wisely
  • We have healthier communities, a healthier economy, and ultimately, a healthier country
• This means finding better ways to:
  
  • Deliver care
  • Pay providers
  • Share and utilize information
• The Affordable Care Act offers many tools to improve the way providers are paid to:
  
  • Reward quality and value instead of quantity
  • Strengthen care delivery by better integrating and coordinating care for patients
  • Make information more readily available to consumers and providers
• Doing so will improve:
  
  • The coordination and integration of healthcare
  • Integration of patients in decision-making
  • The health of patients – with a priority on prevention and wellness

Effective clinical documentation, that is, documentation which best explains the reason for a patient’s care is fundamental to the promotion and achievement of smart effective care choices demanded by all third party payers as well as healthcare care consumers. This means that physicians need to provide (and CDI specialists need to seek out and support):

• An accurate account of the patient acuity and severity
• Clinical rationale for intensity of services ordered and/or performed
• Medical need for inpatient hospitalization
• Evidence-based medical decision making
• Adherence to and justification for deviating from practice guidelines

In light of the above discussion, I pose the question of whether tracking MS-DRG congruency between the coder and the CDI specialists is realistic, practical, or of any material benefit to true effective clinical documentation improvement programs.

That may be a controversial thought considering how many CDI programs begin and the ongoing focus of many on simple CC/MCC capture rates and MS-DRG optimization, but I think that’s where we, as an industry need to be. What are your thoughts and ideas?

Editor’s note: At the time of this article's original release, Krauss was Executive Director of the Foundation for Physician Documentation Integrity.