Clinical Documentation Improvement (CDI)

Short Stay Acute Care Facilities

• Traditionally known as “hospitals” • Can offer a variety of services by order of a

credentialed physician/provider who has privileges at the facility– “inpatient” – “outpatient”

Short Stay Acute Care Facilities

Hospitals that accept CMS beneficiaries agree to inpatient care reimbursement under the Inpatient Perspective Payment System (IPPS) and outpatient care reimbursement under the Outpatient Perspective Payment System (OPPS)

Medicare Reimbursement• It is the responsibility of the hospital to know

when to bill Medicare Part A (IPPS) for inpatient services and when to bill Medicare Part B (OPPS) for outpatient services

• HOWEVER the hospital can only bill CMS (Medicare/Medicaid) based on the services ordered by the physician

Inpatient Services

• Traditionally referred to as an “admission” or “Admit to”– Most patients who spend the night in the hospital

believe they are “admitted”– However, spending the night in the hospital does

not automatically qualify for inpatient services

Inpatient Services

• Uses a day as its basic unit– Day begins at midnight– Any part of a day = 1 day• Patient admitted at 11:30 pm = 1 day

– Count first day of admission but not last day• Discharge patients as early as possible the day of

discharge • Time of discharge are when services are complete not

when the order is written

The Good and Bad of IPPS• Inpatient services are only a “covered” CMS

benefit when medically necessary e.g., when the services could not have been safely provided in a lesser setting

• Hospitals must verify the medical necessity of all inpatient stays/ episodes of care

• Short stay admissions are vulnerable to scrutiny

The Good and Bad of IPPS• The IPPS uses a “bundled” payment system

differentiated by MS-DRG– The MS-DRG payment covers all services rendered

by the hospital during an inpatient stay regardless of the length of stay* (LOS)

IPPS Payment

• The bulk of the cost associated with an inpatient stay is room & board

• CMS bases reimbursement on the G/LOS – 95% confidence interval for LOS based on all

associated claims– Always rounded up to whole number as inpatient

claims are paid per day

RAC AuditsThe IPPS (MS-DRG) payment includes coverage for

several days of tx, the potential for overpayment occurs when IPPS payment is made for a 1 or 2 day stay– Theoretical . . . • if a patient is discharged in fewer days than the associated

GLOS the hospital makes $• if a patient stays longer than the associated GLOS the

hospital loses $

High Risk Admission DRG

Hospital A will receive payment of $6,249 regardless of the services provided and how long the patient stayed in the hospital under the IPPS rules– When patients in MS-DRGs like this have a one-day

inpatient stay CMS evaluates the possibility of overpayment • IPPS payment rather than OPPS payment

Purpose of Utilization Review (UR)

To ensure patients are receiving the correct level of hospital services based on medical necessity

• Procedure Only/same day surgery• Observation/Outpatient services• Inpatient services

Billing at the incorrect level of care is Medicare fraud so a hospital does not bill for services that don’t meet medical necessity

Step Two

• What type of hospital service was ordered by the provider?– Inpatient• Appropriate for hemodynamic instability • Patients who need immediate intervention/tx

– Observation• When in doubt this is probably the right level of care• Appropriate for stable patients with negative diagnostics

who are receiving additional diagnostics

Is the Order Valid per CMS Guidelines?

Not only must an order be present, but it must be unambiguous• “admit to OBS” is no longer considered a valid order by Medicare as of April, 2009– The term “admit” = inpatient setting – The term “OBS” = outpatient setting

Is the Order Valid?

• The term “23 hours admission” is NOT valid– 23 hour observation is an antiquated term– An inpatient admission is billed per day, a patient

can be an inpatient AND remain hospitalized for less than 24 hours

– Observation patients DON’T automatically “rollover” to inpatient status after 23 hours the physician must write a new order to cover care past the 23rd hour

Step Three

• In order to verify medical necessity, CMS mandates the use of a “screening tool”

• UR staff screen for medical necessity by performing an admission review– Is the ordered level of care supported by

documentation in the medical record?

Observation Following Surgery/Procedure

• Requires medical necessity validation• Observation is only justified if something

occurs during the procedure and/or during recovery to necessitate an additional episode of care– Require 4-6 hours of recovery– “monitoring” does not justify observation care – The observation principal diagnosis isn’t the same

as that to justify surgery

How Do You Justify Patient Status?

• Document, document, document• Not only does a hospital need justification for

the patient status, BUT the hospital is also dependent upon physician documentation for their CMS Quality Indicators and reimbursement

Documentation Basics

• Observation care is for diagnostic workup so inpatients should have “evidence of” a concerning disease process to be admitted.

• Always provide the underlying etiology of a symptom i.e., chest pain, syncope, abdominal pain, documented in the H&P in the discharge summary– A diagnosis can be “possible” or “probable” in the

discharge summary if additional evaluation will occur in the outpatient setting

History and Physical

• Specify in your “history of present illness” the following:– Onset of the new/ acute symptom– Is it an exacerbation of a chronic condition– How is the patient’s current condition different

from baseline?

History & Physical

• Specify the current status of all co-morbid conditions– State if resolved• History of pneumonia dx by PCP resolved

– Remains acute • History of pneumonia dx by PCP remains acute

– Is a chronic condition

Coding Guidelines

The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital •Not the admitting symptom•Link the symptoms to the underlying disease process– Fluid volume overload 2/2 ESRD

Documentation Guidelines

Avoid perpetuating the admitting complaint as the Pdx, update your diagnoses each progress note/daily •Clearly state when the etiology of the admitted complaint is determined if it’s symptomology was present on admission (POA) – Disease processes like pneumonia, SIRS, and sepsis

should always be noted if the symptoms were POA

Documentation Guidelines

Clearly state when a differential or working diagnosis is ruled out or confirmed in the progress note and/or discharge summary – Unstable angina secondary to CAD remains likely

cause of the CP– Pneumonia ruled out, abx stopped

Documentation Guidelines

There can still be “evidence of” a disease based on presenting complaints even when not confirmed with diagnostics•Aborted stroke 2/2 TPA intervention•Evidence of gram negative pneumonia (HCAP) 2/2 recent hospitalization and dialysis

The Value of a Concurrent ConditionMedicare identifies diagnoses (by ICD-9 codes)

that require additional resources during hospitalization when not intrinsic to the PDx

These diagnoses are separated into those that minimally resource use (CC) and those that greatly resource use (MCC) this stratification creates the “tiers”

What is The Clinical Documentation Improvement (CDI) Program?

Because clinical terms don’t often correspond to ICD-9 codes, many hospitals have a CDI program.

RNs and/or coders who work collaboratively with providers and coders to bridge the gap between the data contained in the medical record i.e., test results, nurses notes, consultant notes, etc., and what is available for coding.

How Does CDI Work?

The CDI nurse establishes and updates a working MS-DRG based on the principal diagnosis, principal procedure (if applicable), and any concurrent conditions that are classified as a CC or MCC based on documentation by treating providers i.e., H&P, progress notes, discharge summary, etc.

Chart QueriesWhenever there is clinical evidence suggestive of a

more definitive Pdx and/or the presences of an incomplete or missing diagnosis, i.e., a potential CC and/or MCC, the CDI specialist will “query” the physician to interpret the clinical evidence.NOTE: Queries aren’t only to reimbursement

Chart Queries

As with direct patient care, the CDI nurse presents relevant findings to the physician for review– CDI staff don’t evaluate the “quality of care” – The focus of CDI is ensuring provider documentation

reflects the clinical evidence in the medical record and can be “captured” by ICD-9 codes

Chart Queries• CDI staff are not allowed to “lead” a physician

to a particular response– CDI staff can’t pose yes/no questions – CDI staff can’t tell you what diagnosis to write

• When possible, CDI staff will give the provider the diagnosis commonly associated with the clinical evidence that can be captured by ICD-9 code

Chart Queries• Coders can’t infer or assume so sometimes

CDI staff must ask for documentation that seems obvious to the provider and/or to “link” a symptom to a diagnosis

• A provider can always disagree or state the condition isn’t clinically significant or is an incidental finding

Reminders

• Provide rationales/medical necessity for all orders justify the complexity of your patient

• Refer to the H & P to address ALL presenting signs/symptoms with known, suspected or possible diagnoses

• State when a differential dx has been confirmed or ruled out