As industry focus has expanded to include risk adjustment and value-based payment, documentation accuracy is key. Both government and commercial payers now require providers to document more specific clinical detail to meet medical necessity and reflect care quality. Clinicians must do all they can to capture the true picture of the patient by way of clinical documentation.
Organizations across the country enlist teams of clinical documentation integrity (CDI) specialists to help ensure all diagnoses reported in the medical record are accurate and complete according to CMS and Coding Clinic guidelines.
CDI specialists help hospitals assess critical aspects of the patient's story so they are not lost in translation between medical treatment and insurance billing, explained Julie Salomon, RN, BSN chief product owner of CDI, quality and physician content for 3M Health Information Systems Division.
Here, Ms. Salomon describes the major developments in CDI, the top challenges for CDI leaders, key performance indicators that revenue cycle leaders should keep an eye on and how organizations can thrive in a value-based care environment.
Editor's Note: Responses were edited for length, style and clarity.
Question: What are the major developments you've seen in CDI, especially related to the expansion into the quality space?
Julie Salomon: In the beginning, CDI was all about resource consumption and getting the right principal diagnosis. Now, it's expanded beyond principal diagnosis, and is more about having a full accurate and complete picture of the patient. It's about knowing how sick the patient was, how much risk of mortality did the patient have and whether mortality is occurring when it should not. Providers now get penalized for things that may have looked like they should not have occurred when, in actuality, the patient may have had an underlying condition that set them up for that type of disease process. Related to the expansion into the quality space, it is really important to tell the entire patient story and not just a piece of the story or have those pieces separated.
Q: You regularly engage with CDI leaders across the U.S., what are the top challenges, related to quality, that they voice?
JS: I have worked with a wide range of our clients, from small facilities to large integrated systems. A lot of the challenges CDI leaders face are very similar. They're all being asked to do a lot of work that has not traditionally been theirs to do. When they started out, their primary purpose was to identify the correct DRG category to cover resource consumption. Now they are asked to understand and define quality indicators, clinical validation, present on admission and value-based care. This means that CDI teams are being asked not only to reflect additional diagnoses such as different types of comorbidities, but also additional patient information such as social determinants to tell the entire patient story.
Another challenge is that CDI folks are asked to step in to review quality indicators such as AHRQ patient safety indicators, which can lead to a penalty if not properly noted. Quality indicators traditionally belonged to the quality team where the vast majority operated retrospectively. The challenge of reviewing retrospectively is that if we wait to capture things after discharge, it potentially does not get picked up properly – creating a tremendous amount of manual work for the coding team. Best practice would include the quality team concurrently addressing quality indicators. In the absence of a concurrent quality team, the pressure is on the CDI specialist to close the documentation gaps to prevent a retrospective hold.
Additionally, there are a variety of different severity and risk adjustment methodologies in the industry. Many hospitals now use CDI specialists to manually collect information for the different methodologies. One example is the AHRQ Elixhauser Methodology, which uses comorbidities to stratify risk. That is just an example of one model that attempts to reflect the risk of the case to portray the complexity of the population in reflecting positive patient outcomes, which equal quality care. The challenge of meeting all the different documentation requirements for many methodologies creates overwhelming manual work for clinical documentation specialists, quality teams and requiring additional data specialists to examine cases post coding.
Q: What types of methodologies are important to ensuring accurate quality reporting?
JS: From a purely clinical standpoint, the most important thing is capturing secondary diagnoses correctly and reporting the reason the patient reported to the hospital accurately. One thing I see happen in a lot of hospitals is they may pick a principal diagnosis that is not the most clinically significant because they are so focused on financial reimbursement. For example, a hospitalized chronic obstructive pulmonary patient with exacerbated COPD and pneumonia. From my clinical perspective, pneumonia is the acute process that most likely exacerbated the COPD, but for a time period, COPD was paid at a higher rate with the pneumonia providing a major complication or comorbidity when secondary. Coding Guidelines allow either diagnosis to be sequenced as the principal diagnosis as long as it occasioned the admission and met medical necessity. If that patient died, on paper we have a patient who died from COPD exacerbation, which is typically a fairly treatable condition even when exacerbated. However, if pneumonia is on board, that does increase that likelihood of death significantly. From a clinical and infectious disease perspective, I would want the pneumonia to be the principal diagnosis especiallyin the instance where the patient has a more complex bacteria such as pseudomonas aeruginosa a typical colonizer of COPD patients. There is a vast difference between an exacerbated chronic condition and a complex pneumonia which increases risk for other significant systemic issues such as sepsis. Quality and risk adjustment methodologies are more accurately portrayed when reflecting the clinical complexity of the patient.
There's also been a lot of talk in the industry of how we can do a better job in providing health care to all populations to avoid catastrophic care. Industry and government leadership struggle with the need to provide equal care across the population. Health equity has been identified a possible next step to reduce risk for all populations. Here again CDI, quality and coding teams become the front line to collect additional factors around social determinants of health, patient zip codes and other factors related to health equity.
Q: What are the most important things that an organization can do to help them succeed in a value-based environment?
JS:It is really important to leverage technology in the CDI space. Gone are the days when we could take a patient work list and decide to review 85 percent of those records. We really cannot do that same old-fashioned manual review with all the increased documentation needs. Without technology, we are not going to be able to get to the correct cases to meet requirements of various industry methodologies. To do our job, we have to let technology bring the correct cases to us. Technology can auto populate worklists at risk for denial or identify bundled cases. The complexity of the types of reviews means we need to let technology surface the appropriate cases we need to see as opposed to the old hunt and peck method. I really think to get that whole patient picture in any environment, be it value-based or DRG-based payment, we really must use technology to help identify and prioritize what cases CDI teams need to spend their valuable time digging into.
Q: What are important KPIs for a revenue cycle leader to track and manage?
JS: Traditionally, revenue cycle leaders have focused on financial reimbursement. In my view, if we focus on quality, the financial pieces will follow. When we really complete the patient picture, all of these metrics and KPIs that we want to measure or realize will tag along. Things I would consider important if I were the leader would include reporting on severity of illness and risk or mortality for the population. We want to avoid being penalized for quality, so if I have a patient safety indicator or a hospital-acquired condition, how can I avoid that? Was it truly a complication or is it being triggered because a crucial underlying condition(s) did not get reported? It is about identifying what is really a quality penalty and what is due to missing or unreported documentation. I would want to use those metrics to drive change in my organization. If I do have a real quality issue, then it can be identified, addressed and corrected which ultimately impacts patient care.
Q: Is there anything else you'd like to share about the importance of CDI?
JS: CDI is especially important for capturing the full patient story. Given the pandemic, it becomes crucial. There are a lot of organizations that have cut back on their CDI team activities, including scaling back the conversations and clarifications with providers. Other organizations have furloughed CDI staff all together. In my opinion, this lack of clarity will result in gaps in the data as we go forward. There will be significant clarifications that will not occur at individual hospitals, systems and enterprises. As a result, we will have an incomplete data pool to research and learn important information around COVID-19 cases which could definitely impact reimbursement, quality risk scores and more importantly patient care.