Q&A: Advance CDI efforts by expanding reviews beyond low-hanging fruit
Q: At what stage should an established program most likely experience a reimbursement plateau? One may naturally expect the physicians to improve as CDI programs hammer them with education. After we’ve gathered all the low-hanging fruits and go for the mangos? We ran the top principal diagnoses and also top diagnoses for our system. We are a home-grown program, about three years old now. Our team made $6 million last year. I know there are many query opportunities and ideas for program expansion but how do we find the right areas for our facility?
A: I am unaware of any industry standards that identifies a timeline of expectations for a plateau of reimbursement/physician documentation improvement. If you have a relatively stable medical staff with few changes, the program should mature and demonstrate physician documentation improvement more quickly than an organization that experiences high turnover of physicians, such as a university or teaching hospital. A teaching hospital may never plateau as the influx of residents and the constant rotation among specialties means educating physicians and capturing the “low hanging fruit” never ends. Each organization will have their own rate of turnover and educational needs for medical staff.
Such programs would have a lower query rate but maintain increased levels of CC/MCC and severity of illness/risk of mortality (SOI/ROM) capture. In other words, the physicians have retained and applied the education, they require less questioning but their documentation supports higher reimbursement levels.
The second variable in this equation is that as a CDI program matures the staff will find “different trees of low-hanging fruit” to pick. At the beginning, you learn to recognize potential documentation opportunities amongst the apples and oranges and begin to see a decrease in queries related to these but you learn there are opportunities in the lemon trees and the mangoes.
Lastly, organizations are constantly adding new services, new procedures and with each change CDI programs may identify entirely new opportunities. In other words, I have not seen in my experience a leveling off but more of an evolving focus as a program matures.
Self-education and participation in CDI networking are important in advancing your own career, your own knowledge, and your CDI program efforts. If you do not currently have tracking systems in place for individual CDI specialists’ and individual physicians’ query behaviors, you may want to. This might identify specific learning needs for individuals that could be targeted. For example, what diagnoses are the CDI specialists querying for? Does one CDI staff member miss sepsis opportunities or are there opportunities the entire team needs to learn about? If there a specific physician that needs intervention on a particular diagnoses?
Most successful CDI programs work closely with their coding teams. Expand on this collaboration by having the coding staff bring forward any trends or difficulties they’re seeing in daily practice. Ask to review any retroactive queries for trends and trouble spots. Identify any documentation improvement opportunities the CDI staff may have missed. The idea being, you and your CDI team won’t miss that opportunity next time.
If you do not have access to your organization’s Program for Evaluating Payment Patterns Electronic Report (PEPPER), seek out access. PEPPER is produced by CMS and it compares your organization to like organizations within your region. It identifies where you maybe an outlier for specific diagnoses and CC/MCC capture. You may be able to identify improvement opportunities in areas where you are a low outlier compared to your peers.
I often found my new fruit by reviewing the code set. Just opening up the code book and seeing what specificity was needed in code assignment for specific diagnoses often demonstrated for me areas of needed improvement. I would suggest doing that with theICD-10-CM code book. You can start asking questions related to ICD- 10 now so that the learning curve will not be so steep come October of next year.
Lastly, an exercise I suggest for new CDIs and one that might require repeating as the definitions do change is to take the list of CC/MCCs and highlight those diagnoses that are often seen within your population. You may find there is a “fruit basket” just sitting there that you never considered. If you identify codes that you have not thought to ask for look them up in the code books and learn what terms are needed to support their documentation. I promise you this effort will bring to light at least one diagnosis common to your population that you might not be capturing on a regular basis.
Wikipedia tells me there are over two thousand different fruits in the world so you have many to harvest!
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.