Six New Year’s Resolutions for Coding and CDI Departments

From evolving your CDI department to a population-centric approach to understanding the impact of electronic medical record technology on CDI program outcomes are among six resolutions offered by the author.

Happy New Year! It’s now officially 2018, and even though we are already a full quarter into the federal fiscal year, it’s never too late to think about what you as a leader of a clinical documentation integrity (CDI) or coding department can resolve to do to improve your performance indicators in a variety of key areas.

Taking the opportunity to recast your priorities is an important task, and it requires a little forecasting of the future. In an effort to jump-start your thinking, here are a few key areas of emphasis that routinely pop up in working with many of our clients, including community hospitals and large, complex academic medical centers.

Key Perspectives for CDI Programs

1. Evolve your CDI from a patient-centric to a population-centric approach, with an emphasis on improving the quality and accuracy of claims data used for risk adjustment and population health management.
2. Develop a core competency in risk adjustment from both coding and CDI perspectives. This typically requires developing an understanding of how Hierarchical Condition Categories (HCCs) are used in both value-based payment and alternative payment models by the Centers for Medicare & Medicaid Services (CMS), and translating that to changes in how coding and CDI work together to achieve high-quality documentation by providers.
3. Examine how physician care delivery and contracting models have impacted your organization over the past 12 months; specifically, look at how BPCI (Bundled Payments for Care Improvement) and Medicare shared savings programs with Accountable Care Organizations (ACOs) may have implications for your CDI program. Reach out to the leaders of the ACO and ask them about the confidence they have in the claims data being utilized to determine payment beyond fee-for-service – and if the physicians understand HCCs and risk adjustment factors. You may be surprised by their answer!
4. Define the landscape for outpatient CDI and determine if your organization can benefit from a CDI presence in outpatient departments such as clinical decision units, emergency services, and short procedure areas. These are areas typically left on the “do not call” list for CDI, but there may be opportunities here to help with medical necessity documentation and denials avoidance. As the lengths of stay for acute-care hospitals continue to decrease, it is never too early to start the CDI process – even if that means simply getting the principal diagnosis routinely documented by the ED physician or resident.
5. Get comfortable with the impact that CDI and coding have on performance measures. Specifically, get outside your department and help your colleagues in clinical quality determine the root cause of lagging performance in risk-adjusted payment programs. Is it really a quality of care problem, or a quality of coding and documentation issue?
6. Become more engaged in understanding the impact that poor clinical workflow and sub-optimized electronic medical record (EMR) technology has on the outcomes of your CDI program. Are the technology and tools being provided to clinicians preventing better documentation outcomes from being achieved in your organization? If so, how do you know, and what will you do to help your IT department solve this? These are daunting questions, yet if they go unanswered, the assumption of an under-performing CDI program may be an answer to a myriad of questions being asked by the C-suite.

Why is all of this really important?

First and foremost, the legacy approach to CDI was created with a fee-for service reimbursement model in mind, and we must evolve to support the changing reimbursement landscape with new documentation requirements. Most organizations have now moved beyond the tipping point for where success with value-based payments and participation in alternate payment models such as episodic or bundled payments is garnering more attention by the C-suite.

While fee-for-service reimbursement is still prevalent, there is now an appreciation for how much reimbursement is at risk through both penalties for poor performance and an organization’s inability to capture incentives. Providers are turning their attention to incentive models as well, and this is driving more collaboration between hospitals and physicians than ever before. A key part of that collaboration involves relying on the hospital to provide infrastructure to help meet new requirements for documentation, coding, and data analytics. The need for a CDI program is often discussed as a necessary bridge between providers and their data, which is becoming ever more important.

Risk Adjustment is a New Core Competency

HCCs are becoming increasingly important in the world of value-based payments and alternative payment models. Capturing these high-value diagnoses is key to the concept of risk adjustment, which requires a longitudinal measurement of comorbidities that contribute to the depiction of the expected burden of illness of an individual patient or an at-risk population. These diagnoses must be documented at least once every calendar year for inclusion in the risk adjustment factor (RAF) score for a patient in the CMS risk adjustment model.

In the context of an ACO, these RAF scores can impact reimbursement for single patient encounters, but also for groups of providers managing patients across the care continuum. Focusing your CDI program on just the inpatient hospital services may adversely impact how the RAF is determined for each patient, with the potential to understate patient acuity as diagnoses fall off at the start of each calendar year.

Imagine the impact of missing diagnoses such as chronic renal failure or diabetes in a patient that was not seen as an inpatient during the last 12 months and was purely managed in the ambulatory setting. Conversely, not recognizing diagnoses in the inpatient setting that are HCCs but have no bearing on the MS-DRG assignment can leave potent risk adjustors unaccounted for in the claims data – and it may also result in missing an opportunity to exclude a high-risk patient for inclusion in the Hospital Readmissions Reduction Program.

CDI programs also must begin to appreciate the concept of understated patient acuity. CDI programs focused on just secondary diagnoses that impact the MS-DRG reimbursement methodology have an inherent blind spot for approximately 40 percent of diagnoses codes that are not MS-DRG CCs or MCCs, but are risk adjustors in several of the value-based programs. CDI programs also must begin to work more closely with their colleagues in health information management (HIM) to be certain that all diagnoses that are documented are in fact coded, per CMS coding guideline 19, and that a process for when clinical validation of potentially unsupported diagnoses exists.

Impact of Workflow and Technology on Clinical Outcomes

I’d like to add one final word on the content of documentation being a byproduct of the clinical workflows and technology solutions deployed by any organization. CDI programs have undoubtedly seen the impact (and sometimes, the burden) in real time that suboptimal technology and clinical workflow has on the quality of the EMR. Recognition of technology and workflow in the clinical documentation equation is often fraught with glares and eye-rolls from CDI professionals who simply ask “do I have to do EVERYTHING?”

The quick answer is no, you don’t, but if it doesn’t come from your department, then you are leaving a key variable for your program’s success in the hands of another department that is not necessarily trained to solve these problems. CDI professionals know clinical workflow, coding, and documentation, and are perfectly suited for diagnosing and remediating problems arising from technology and workflow.

For many providers, documentation is no longer completed synchronously with the patient encounter due to a variety of perceived and actual barriers. This results in documentation gaps, inefficient workflow, decreased productivity, and poor reliability in the accuracy of mainstay communication tools like the problem list. The problem list has evolved from an important tool for care delivery to a diagnosis dumping ground in many EMRs. Inadequately constructed documentation templates and pick lists create situations in which more documentation is being repurposed by providers – and that documentation is often lacking the precision and detail required for compliant coding. In addition, repurposing documentation that originated elsewhere in the continuum will have an impact upon what documentation is permissible for use in the coding process. CDI programs should resolve to work more closely with their information technology and electronic medical record committees to become a bridge between the technology solutions and the providers that are using them to document care delivery.

CDI also should develop an “at-the-elbow” presence with providers as they are delivering care, and observe if there are opportunities for better workflow and synchrony between care delivery and documentation. CDI should assist providers with achieving specificity in their documentation and coding through helping them deploy technology tools available to them in the documentation process. CDI programs also should work with IT to make documentation precision a priority over documentation volume, and amplify the needs of providers to make documentation clear, concise, and specific to the encounter. Again, this is not a role that is relished by many in any healthcare organization, but nonetheless it is important for consideration in moving a legacy CDI program to a high-performing unit that is prepared to support the organization as more of its reimbursement is coming in the form of alternative and risk-adjusted payment models.

My colleagues at DHG Healthcare look forward to delving more deeply into a number of the topics touched upon in this article in the coming weeks and months, and we wish everyone the happiest, healthiest, and most prosperous new year.

Program Note:

Register to listen to Talk Ten Tuesday today at 10 a.m. EST when Michelle Wieczorek will discuss her article.