Tip: Break the traditional CDI mindset to survive auditor recoupments

By Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI

CDI specialists need a total change in mindset if they are to survive our current auditor environment.

Let’s take a typical example: A patient presents to the ED with chest pain of three days duration and increasing intensity, worsening over the last day. The CDI specialist reviews the chart, determines the patient’s initial complaint, and notes that the physician ordered a cycle of troponins, as EKGs, an echocardiogram, and a chest x-ray. After reviewing the chart the day after initial admission—in particular the diagnostic test results and the diagnoses documentation—the CDI specialist notes a diagnosis of “acute coronary syndrome” or perhaps “unstable angina.” Equivocal troponins are borderline, and the CDI queries the physician to clarify a diagnosis of non-STEMI. However, the patient also has risk factors for MI consisting of diabetes, sedentary lifestyle (being a truck driver), smoking, and a strong family history of MI with a first relative that recently passed away due to the condition. These factors remain unaddressed.

Although valid enough, instead of a simple NSTEMI query, the CDI specialist could have looked deeper at the context of this patient’s admission. CDI specialists often overlook (and fail to factor in) the patient’s presentation prior to (and during) the admission process.

Traditionally, CDI specialists review the chart by glancing at the documented chief complaint and history of present illness (HPI), proceeding to the diagnostic test results ordered and/or available, quickly looking at the patient past, family, and social history (PFSH), and then jumping down to the physician’s assessment and plan of care. Based on this review process, The CDI specialist then initiates a query when clinically appropriate.

On face value such efforts help the hospital revenue cycle process, enhance case mix achievement subsequently improving reimbursement for the hospital. But the question remains: Does it truly improve reimbursement capture for the hospital, or does this process contribute to increased denials and financial recoupments from third party payers?

Current record review practices may actually lead to an increased level of denials particularly in situations where diagnoses documented through the query process are not substantiated. Furthermore, the work performed in coming up with the conclusion statement of diagnoses that we solicit from the physician is typically not well executed and documented in the record.

Simply put, it is not sufficient to document a diagnosis without the supporting clinical context, including HPI and clinical thought processes of the physician. CDI specialists don’t always think this way, or they believe this to be a case management function. But the reality is that our work as CDI specialists is being undone by auditors.

The Palmetto GBA offered a training focused on query efforts emphasizing an enormous denial rate. (View the PowerPoint “Spotlight on Physician Querying and Coding Specific Diagnosis Related Groups” online)

Out of more than 2,000 cases reviewed roughly half were denied. Why? Physicians don’t always document secondary conditions which may constitute an MCCs until we query for them and while the clinical findings supporting the diagnosis may be scattered throughout the electronic health record in bits and pieces, and even may be documented in our formulated query, the physician may not continuously document treatment and analysis of the complicating condition. And the query is often times not included as a permanent part of the medical record.

Providers often base their denials on: Unnecessary care was provided Codes were incorrectly listed and/or not substantiated by the documented facts of the case Proper documentation was not provided for a claim

What value do CDI efforts actually have if it gets a diagnosis added to progress note, but the facility doesn’t get paid for the entire stay? A total of $3.75 billion was recouped by Recovery Auditors in 2013 as stated in the “Recovery Auditing in Medicare for Fiscal Year 2013-FY 2013 Report to Congress.”

How much of that $3.75 billion could be saved with enhanced documentation? It’s a crying shame given the challenging economic climate hospitals operate in meeting the healthcare needs of the community.

Getting this additional specificity is a matter of properly engaging physicians to promote good documentation habits. A CDI specialist often places queries on the physician’s chart and leaves. Some physicians never answer. Instead of getting angry that they’re not responding, try calling their office and setting up a time to meet the physician. Rather than tell the physician of the benefits, show him/her the benefits in the context of two or three of the clinician’s charts.

It’s really a matter of engaging your physician—that’s what drives them. If you get paid on a merit based incentive payment system—if you treat your patients more efficiently with better outcomes and lower cost—you will get paid for your quality. That’s the message we have to get across to physicians—“You have to show your efficiency and care in your writing. You can’t generalize, doc, you need to show us.”

Without the right documentation, our work will fall by the wayside. The short gains we make today will not stand the test of time. Embrace the concept of “true” documentation improvement versus “case mix documentation improvement.”

Editor’s Note: Krauss is a manager with Accretive Health in Chicago. Contact him at glennkrauss@earthlink.net.