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Clinical Documentation Improvement (CDI)

What Is It?

Why Does It Matter?

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Speaker Information

• James S. Kennedy MD CCSManaging Director, FTI Healthcare

Engaged in Clinical Documentation and Coding Integrity (CDCI) physician/CDS/coder education, training, and process development

• Education and CertificationsMedical School – University of Tennessee - Memphis, 1979Board Certified – Internal Medicine, 1983AHIMA CCS Certification – 2001

• Publications• 2007 – AHIMA – Severity Adjusted DRGs, an MS-DRG Primer• 2009 – ACDIS – Physician Query Handbook• Ongoing – “Minute for the Medical Staff” in HcPRO’s Medical Records Briefings• Ongoing – “Coding Clinic Update” – HcPRO’s CDI Journal (ACDIS)

• Contact 5310 Maryland Way, Suite 250Brentwood, TN 37027-5370(615) 324-8500 – Nashville Office or (404) 460-6250 – Atlanta Office(615) 479-7021 – CellularJames.Kennedy@fticonsulting.com

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What is CDI?

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• Clinical Documentation Improvement (CDI) is the process of preventing and reconciling inconsistent, incomplete, imprecise, conflicting, or illegible provider documentation prior to the final assignment of clinically congruent HIPAA-associated transaction set codes and their submission to fiscal intermediaries or other entities for adjudication.

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Courtesy of C. Trey LaCharité, M.D., University of Tennessee Medical Center, Knoxville

Questions:•Why on Levo(Phed)?•Why on Clinda/Vanc?•Why on Primaquine?•Why unresponsive?

•Why is AST/LDH/CPK so high?•Significance of +HIV w/CD4 of 98?•Significance of Sputum w/Candida?

•Cause of thrombocytopenia?

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Foundation of CDIs

• Physician/Provider• Definition of terms• Diagnosis of patient condition• Documentation in the medical record

• Clinical Documentation, Ancillary, and Coding Staff• Delineation of documented diagnoses or treatments in the

context of the patient’s treatment and the limitations of HIPAA-associated transaction set nosologies.

• Deciphering inconsistent, incomplete, imprecise, conflicting, or illegible documentation and clarifying it prior to claim submission.

• Everyone• Defense when held accountable by outside entities

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Servant Leadership

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Why This is Important to Physicians

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Provider Profiling of Quality and Efficiency

http://healthcaredisclosure.org/docs/files/PatientCharter040108.pdf

Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs:

Ensuring Transparency, Fairness and Independent Review

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Provider ProfilingEpisode GroupersCase Mix Index 0.82

Cost Index 1.17

High Cost Index is Less Efficient

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Physician ProfilingUnited Healthcare - 2010

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Impact on PhysiciansDirections for Healthcare Reform

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Impact on PhysiciansDirection for Healthcare Reform

• Increasing Use of Bundled Payments• Hospitals and Physicians paid out of the same payment for

current admissions and all care within 30 days of discharge• Addresses “Preventable” Readmissions

• 18% of Medicare’s inpatient expenditures is for readmissions within 30 days

• $12 billion spent annually spent on “preventable” readmissions

• Places physicians at risk for efficient hospital resource utilization.

• Requires physicians to understand and document completely consistent with MS-DRG methodologies

Source: Medicare Payment Advisory Commission

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• HCAP Pneumonia requiring Zosyn & Vancomycin

•DRG 195 w/o cc/mcc– Simple Pneumonia & Inflammation – 0.7096 (LTC .4864)

• Pneumonia prob. 2° pseudomonas & MRSA requiring Zosyn & Vancomycin – Not HCAP

DRG 179 w/o cc/mcc – Respiratory Infections & Inflammations - 0.9861 (LTC 0.5980)

• Sepsis due to Pneumonia

•DRG 871 – Septicemia or Severe Sepsis with MCC – 1.9074

• DRG 194: With CC – 1.0152

(*LTC –0.6138)

• DRG 193: With MCC – 1.4796

(*LTC 0.7620)

• DRG 178 With CC – 1.4887

(*LTC 1.7176)

• DRG 177 With MCC – 2.0667

(*LTC.8886)

•DRG 871•With MCC – 1.9074•(*LTC .8713)

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*(LTC) Long-Term Acute Care are reimbursed by CMS at a higher level (per 1.0 severity weight for resources needed for >/= LTC 25 day complex patients

PneumoniaMS-DRG Options

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Cardiac SurgeryAcute Care Episode (ACE) Project

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CCs & MCCs in ICD-9/ICD-10CC/MCC Code Description

MS-DRG CC I5020 Unspecified systolic (congestive) heart failure

MS-DRG MCC I5021 Acute systolic (congestive) heart failureMS-DRG CC I5022 Chronic systolic (congestive) heart failure

MS-DRG MCC I5023 Acute on chronic systolic (congestive) heart failure

MS-DRG CC I5030 Unspecified diastolic (congestive) heart failure

MS-DRG MCC I5031 Acute diastolic (congestive) heart failureMS-DRG CC I5032 Chronic diastolic (congestive) heart failure

MS-DRG MCC I5033 Acute on chronic diastolic (congestive) heart failure

MS-DRG CC I5040Unspecified combined systolic (congestive) and diastolic (congestive) HF

MS-DRG MCC I5041Acute combined systolic (congestive) and diastolic (congestive) HF

MS-DRG CC I5042Chronic combined systolic (congestive) and diastolic (congestive) HF

MS-DRG MCC I5043Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure

I509 Heart failure, unspecified

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Hierarchical Condition Coefficients (HCCs) depend upon diagnoses assigned in both physician and hospital inpatient and outpatient venues.

Used in other demonstration projects integral to the PPACA

Unless physicians report appropriate severity and specificity in their notes, their patients’ illness severity are artificially underrepresented.

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Medical HomesHCC Methodology

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Medicare Advantage HCC methodology — Example

RISK FACTOR

No Chronic Conditions

Base Payment

Cancer LungMetastatic

Bone Cancer

Protein Calorie Malnutrition

(PCM)

Pressure Ulcer, Hip

65 yo Male 0.328 0.328 0.328 0.328 0.328

Cancer Lung

1.053

(No Credit for “Hx of Cancer”)

Metastasis to Bone

2.276 2.276 2.276

Protein Calorie Malnutrition

(PCM) 0.856 0.856

Pressure Ulcer, Hip

1.153

TOTAL HCC SCORE 0.328 1.381 2.604 3.560 4.713

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HCC Methodology

Imperative that physicians document diabetic complications impacting HCC score.

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2010 IPPS Final Rule: Quality Measures

AHRQ Patient Safety Indicators  

● PSI 04: Death among surgical patients with treatable serious complications

● PSI 06: Iatrogenic pneumothorax, adult

● PSI 14: Postoperative wound dehiscence

● PSI 15: Accidental puncture or laceration

● IQI 11: Abdominal aortic aneurysm (AAA) mortality rate (with or without volume)

● IQI 19: Hip fracture mortality rate

● Mortality for selected surgical procedures (composite)

● Complication/patient safety for selected indicators (composite)

● Mortality for selected medical conditions (composite)

Hospital performance in these will affect reimbursement after October 1, 2013

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Define – Diagnose – Document “Think with Ink”

• Physicians are essential to CDI• Unless the provider defines, diagnoses, and documents

conditions and treatments using ICD-9-CM (and ICD-10 after October, 2013), administrative databases will not know that these existed

• Physician integration strategies are tied to CDI• For physicians to perform well in healthcare reform, the

data has to be correct• Facilities have a shared interest in data integrity

• Increasing accountability for clinical congruence of

ICD-9-CM codes• We are the solution

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Thank you!

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