Improving Performance Outcomes and the Financial Health of Your Organization

While it is now officially calendar year 2017, we are a full quarter into the 2017 federal fiscal year. That said, it is not too late to think about what you as a leader of a clinical documentation improvement (CDI) or coding department can resolve to do to improve your performance outcomes in a variety of key areas. 

Perhaps you have already considered some resolutions as part of a department planning exercise to go along with your performance improvement plan, or as a result of responding to some regulatory requirements. But in case you haven’t given much thought to it or formalized the process, here are some items to consider that come from our experience in working with our clients, and what we recommend they do in the coming year:

Resolve to find greater value in external benchmarking.

This might seem redundant on the surface, because we live and breathe performance metrics. That said, comparing one’s own performance against an arbitrary benchmark may not give you the feedback your department needs to hit its desired performance mark. We challenge our clients to resolve to improve their use of data from third-party sources in these ways:

1. Perform an annual CDI operations and quality assessment utilizing a third party.

• Surprisingly, while the coding department often undergoes external review annually as part of the PI plan, the CDI program is typically not reviewed by an external third party. Objective feedback from an external source can provide a fresh perspective. This type of review can be extremely valuable in identifying best practices in productivity, workflow, and opportunities for education and further standardization. Typically, the vendor reviews 10 charts at random for each CDI specialist and evaluates the quality of the CDI review, the compliance and quality of the query, and the connectivity downstream through the physician documentation and final coding of the record. In addition, the workflow is assessed as well as specific departmental policies, procedures, and query tools to identify gaps, inconsistencies, or need for updates. This relationship can also be leveraged to provide ongoing education to the CDI staff, especially with regard to changing healthcare reimbursement requirements to help the CDI department remain relevant.

 2. Change the annual coding review vendor every three years, and maintain an independent relationship between contract coding vendors and external third-party reviewers.

• Consider placing fresh eyes on your coding program. Gain insight from a company that is not familiar with your coding practices in order to bring in a new perspective on coding. Because the interpretation of coding guidelines can be somewhat subjective, leading to variation in practice, we encourage clients to look at a different vendor every few years to achieve a more comprehensive approach, rather than focusing on the criteria of a particular vendor. In an organization utilizing a third party for contract coding, we also encourage organizations to place a buffer between that contract coding vendor and the vendor selected to do an independent review of the coding quality to ensure complete independence and integrity in the review process.  

Resolve to establish a more meaningful relationship with the CFO.

If there was ever a reason to work better with the finance department, value-based and alternative payment models are that reason. In our work as consultants, we are continually reminded how the traditional metrics for measuring the success (and value) of the CDI department, such as the case mix index (CMI), are inadequate surrogates for measuring how the CDI and coding departments are faring with the risk-adjustment methodologies used by Medicare in the payment reform models. This blind spot is evidenced by a CFO being insulated from the impact that clinical documentation has beyond the MS-DRG. It is one thing to be familiar with Hospital Value Based Purchasing (HVBP) program, Hospital-Acquired Conditions Reduction (HACRP), and Hospital Readmissions Reduction Programs (HRRPs), but it requires additional training to understand the relationship between clinical documentation on performance within these programs. Additionally, Medicare continues to introduce more initiatives, such as the Mandatory Episodic and Bundled Payment models, which are highly dependent upon the quality of clinical documentation and coding.

CFOs can no longer rely strictly on MS-DRG-based metrics to determine how their departments are performing. CDI and coding departments must understand the impact of CMS payment reform on their roles so they can help educate and lead the finance department through a transition to more contemporary metrics, which include coding depth, severity of illness (SOI), and risk of mortality (ROM). And this leads us to our final resolution.

Resolve to create a more meaningful CDI and coding dashboard that incorporates the concepts and measures for risk adjustment.

Defining CDI and coding programs by CC/MCC capture rates and CMI has encouraged many organizations to sacrifice completeness of the health record. To meet demanding productivity metrics, many organizations have encouraged CDI and coding staffs to focus only on those diagnoses that impact MS-DRG assignment. Thus, CDI specialists target those diagnoses classified as CCs or MCCs, and coders often release the bill when there are enough codes to maximize the reimbursement, with maybe a backup MCC or two. Ironically, this practice is detrimental when payments are made under value-based mechanisms.

Because very ill patients are at higher risk for adverse outcomes, it is imperative that these patients, who often have diagnoses classified as MCCs, can be adequately risk-adjusted to “justify” poor outcomes. Metrics that can support risk adjustment efforts include coding depth and use of an APR-DRG grouper. The goal is not just to report as many codes on a claim as allowed, but to also ensure the quality of those diagnoses by reporting them to their highest specificity, even when they are not classified as a CC or MCC. Leveraging APR-DRG provides insight into the complexity of the patient’s condition within the domains of SOI and ROM by considering the interactions of all the reported conditions, not just those classified as a CC or MCC. Even a case without a diagnosis classified as a CC can demonstrate a higher SOI or ROM with complete and accurate documentation to support precise code assignment. 

So in this New Year, resolve to improve your performance outcomes and the financial health of your organization.