The 2017 Inpatient Prospective Payment System (IPPS) guidelines contain several fundamental changes, and certainly some challenges insofar as clinical documentation improvement (CDI) and coding practices are concerned.
As an advocate for integration of coding guidelines into our CDI practice, the 2017 IPPS certainly offers an opportunity for tighter collaboration between the two domains. Practically speaking, if the health information management (HIM) department and CDI department aren’t speaking daily and meeting formally during DRG reconciliation reviews, this is a golden opportunity to begin that practice. In fact, these guidelines are a call to action to involve others in readiness activities.
I purposefully titled this article “Preparing Your Organization for the 2017 IPPS” because the reach of these changes will impact multiple constituencies, including the medical staff and compliance office. Each has a place at the table when it comes to developing a robust strategy and planning for how to address the inherent conflict surrounding the concept of clinical validation (and perhaps in a couple other areas ripe with opportunity). Given the short time frame we have to develop and execute a plan, a first step may be to identify situations in which coders and CDI specialists will need guidance in how to respond to the changes. Some of these areas include:
A renewed emphasis on diagnosis specificity: CMS is reinforcing the need to report the most specific codes, and also confirming that specificity can be used as the sole basis for clinical denials. This affects physician practices in a significant way. In the run-up to ICD-10-CM/PCS implementation, the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) announced guidance allowing the use of unspecified codes on certain Medicare claims. Specifically, the language read as follows: “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family. However, a valid ICD-10 code will be required on all claims starting October 1, 2016.”
In a FAQ sheet released last week, CMS reaffirmed that this allowance will be coming to an end (and in fact, the specificity requirement should be in place now, given the time that physicians have had to prepare).
Organizations should take the next month or so to get familiar with their most frequently assigned unspecified codes and work on them, with a priority to heighten the awareness of which situations contribute to their assignment. Are the physicians coding via the electronic medical record (EMR), for example, and can an EMR template be enhanced to require the selection of a more specific code? For our CDI colleagues, non-specific codes can impact the representation of patient acuity and risk-adjusted outcome data, and are an indication for CDI queries. Run a report from the financial or coding system and see which inpatient codes are being assigned that are unspecified, then work to prioritize and reduce their prevalence through concurrent queries, EMR remediation, and physician education.
“With “as a linking mechanism: in the new guidelines, the word “with” in the alphabetical index, numeric description, or code title will have an automatically presumed relationship under ICD-10. The cause and effect is assumed regardless of the physician documentation, unless the diagnoses are documented as not being linked (or linked to other diagnoses). An important example is hypertension with heart failure. On Oct. 1, if a patient has hypertension and heart failure, the cause-and-effect relationship is assumed unless the physician notes that the diagnoses are not related. Organizations should look at how this will impact performance in the DRG triplet of 291, 292, and 293. Patients who present with hypertension, CKD, and acute CHF will move to 291 – the highest-weighted DRG – by default and not require a CDI review or coding query to the physician to associate the diagnoses. This is an important concept to review with clinicians, quality, revenue cycle, and finance peers because of the intentional DRG shift that will occur and how that translates to impacts on the case mix Index, quality metrics, and CC capture rates.
Instructional notes regarding coding all documented diagnoses: the guidelines contain an instructional note that coders are not permitted to selectively dismiss a diagnosis that has been documented by a physician. Given that there has been great variety in the standard of practice for reporting a diagnosis that appears once in a record (or that which may not be supported by clinical indicators), this instructional note positions coders to report codes for diagnoses that have been documented irrespective of their judgment as to the strength of clinical evidence or the continuity of documentation, as far as the monitoring and treatment of the diagnosis. As our friend and colleague Dr. Jim Kennedy points out, this is not an opportunity for coders and CDI specialists to check their brains at the door. This is an opportunity for coders and CDI specialists to begin working as a unit with their compliance officer and medical staff peer advisors to determine the applicability of prior practices and policies.
It is important to recognize that many of these policies were written specifically in response to Recovery Audit Contractor (RAC) activity or clinical denials, focusing on the lack of clinical support of a diagnosis via clinical indicators. As clinical validation will continue to be part of the scope of work for the RACs, organizations need to determine how they will respond to the instructional note guidance. Some tactics to consider for situational readiness may include:
- Determining how the CDI specialist will respond on a concurrent basis to a diagnosis in the record that does not appear to be actively monitored or treated. Is the CDI specialist expected to query the physician? If so, on what basis, and is there a need for a new type of query to address this situation?
- Determining how a diagnosis discovered post-discharge by the coder is to be handled if it lacks the support of clinical indicators or does not appear to carry through to the progress notes. Should an escalation protocol be triggered to initiate a second-level review by a clinician?
- Determining which coding guidelines or practices require recalibration in order to be compliant with the instructional note guidance.
These 2017 guidelines highlight the role of the CDI specialist and underscore the need for collaboration among the coding team and clinicians more strongly than ever. As clinical documentation and coding continue to evolve, this is a wonderful opportunity to determine how and when we converge so that our interactions with clinicians are consistent, productive, and able to achieve the desired outcome.