August 1, 2011

A Value-Based Proposition
By Selena Chavis
For The Record
Vol. 23 No. 14 P. 14

Long driven by reimbursement concerns, many clinical documentation improvement programs will need an expanded identity to meet future compliance needs.

Faced with the need to meet documentation challenges head-on to comply with various federal regulations, most healthcare organizations have already given the nod to clinical documentation improvement (CDI) programs. Since these initiatives have a proven track record for improving revenue cycle initiatives and patient outcomes, they have become an essential element to the overall well-being of hospitals and healthcare organizations in today’s lean, value-driven climate.

And the prominent role CDI has taken in the delivery of healthcare is not expected to diminish, according to professionals across the HIM field.

“CDI will continue to grow in its impact to facilities,”  says Starla Stavely, director of HIM at Jennie Stuart Medical Center in Hopkinsville, Ky. “Without a CDI program, the data doesn’t always reflect what is really happening with the patient.”

Specifically, the need for a clear and accurate picture of a patient’s stay will be crucial going forward and although many facilities have well-established CDI programs in place, experts suggest they will not live up to looming expectations on the federal front. Faced with the lofty aspirations of Medicare’s national hospital value-based purchasing (VBP) program, healthcare organizations will need to not only enhance CDI program delivery but also shift to a more quality-based focus.

“CDI programs became popular and came about in response to reimbursement concerns. The training and analysis that has been given has been primarily focused on reimbursement,”  says Jon Elion, MD, FACC, president and CEO of ChartWise Medical Systems. “This focus does not ensure you get everything you need, though. If you go after being as complete as possible, you are going to get everything you need for appropriate reimbursement.” 

Mandated by the Patient Protection and Affordable Care Act, VBP is scheduled to take effect in October 2012 and will reimburse hospital care based on quality of care, not just the quantity of services provided.

“CMS [the Centers for Medicare & Medicaid Services] does not want to pay for something that is not working well, and they have all sorts of methods for gathering information on what works and doesn’t work,”  says Alice Zentner, RHIA, of TrustHCS, pointing to established core measures that healthcare facilities will now be expected to meet. “They will have hospitals track how they are treating particular diagnoses. … If the hospital follows all prescribed measures, CMS will pay more for it.”

VBP’s Impact
The move to VBP represents a major shift in quality focus that most hospitals are not prepared to meet, according to a recent study conducted by Texas-based VHA Inc, a national network of not-for-profit healthcare organizations focused on improving operational efficiency and clinical outcomes. In a 2010 national analysis of hospital performance, the organization recorded a median VBP score of 53. To maximize reimbursement under VBP, hospitals will likely be expected to score higher than 70.

“In regards to VBP, the impact for CDI is huge,”  Stavely says, adding that there will be a heavy emphasis on clinical knowledge and coding expertise. “It has to be a perfect distillation of those areas where all information is captured at the point of care.”

Elion offers an example of how VBP will impact CDI by focusing on one particular element: the profiling of physicians and hospitals in regard to their resource utilization.

For instance, consider a case in which a patient’s gallbladder is surgically removed. Postoperatively, the patient develops a fever, abdominal pain, and an increased heart rate. Tests reveal an elevated white blood cell count. A doctor orders an abdominal x-ray, a CT scan of the abdomen, and blood cultures to check for infection. While waiting for a consult with an infections disease consultant and test results, an IV dose of ciprofloxacin is started. All findings and plans are carefully documented in the chart. Ultimately, the patient gets better and is discharged.

In such a scenario, Elion says a major problem will surface due to the way patient care was documented. Based on the information provided, the chart will get coded as an uncomplicated cholecystectomy. Because symptoms and lab tests do not on their own change the coding or reimbursement, the physician would appear to be overutilizing resources as most of the orders made are not indicated for a routine cholecystectomy.

“The physician should have included the terms ‘probable peritonitis’ and ‘probable sepsis’ in his documentation, in which case the resource utilization would have been deemed appropriate,”  Elion points out, noting that if a CDI specialist had caught the missing details, the gap between appropriate utilization and overutilization could have been closed.

Current CDI efforts in many facilities fall short of the needed focus on quality measures such as overutilization. Instead, they often zero in on documentation practices that will meet the specificity needs for capturing the most severe Medicare severity diagnosis-related group. Going forward, Elion says a shift to a quality-based focus that provides a complete picture of patient care will be needed.

“What should have been the focus from day one was a complete, 100% accurate picture of a patient’s stay,”  Stavely says. “You can’t get better payment than 100% accurate.”

Shifting the Focus
“Clinical documentation should be a thorough record of the diagnos(es) made, symptoms observed, treatment procedure planned and executed, the care provided, the outcome of the treatment, and clinical assessment of the entire treatment process.”  This quote from “Guidelines for Improvement in Clinical Documentation” by Tom Billmore provides a solid definition for what Elion believes future CDI programs should be based on.

Shari Breuer, principal with the Claro Group, takes it a step further, noting that a renewed focus on quality will bring more physicians on board with CDI goals. “If you take away the concept that it is a coding focus, it elevates the program,”  she says. “If you start bringing in quality, it really changes the conversation for the physician.”

The bottom line, according to Breuer, is that if documentation is truly capturing and telling the story of a patient’s stay in a facility, then proper reimbursement will follow.

 “Programs that have sustained themselves are those that have shifted to a quality focus,”  she says. “Then you have an accurate picture of how sick the patient is and the severity of the illness. Accuracy will build the case for reimbursement.”

In some cases, hospitals and healthcare facilities may have to lose in order to gain, according to Elion. Noting that he has audited hospitals that have had more than $1 million in overpayments, he says when the CMS determines there is a systematic approach to documentation and coding practices causing the overpayment—often originating with overzealous CDI programs—then the hospital can be liable for treble damages (triple the amount).

“If you put in a CDI program based on quality, it may be a good thing for reimbursement to drop by $1 million,”  he explains, pointing out that the goal is accurate documentation and coding practices to avoid triple penalties. “Appropriate reimbursement is a good thing.”

Taking CDI to the Next Level
Clinical integration is garnering attention and gaining traction as healthcare experts consider how best to meet VBP’s overarching goals. The concept refers to the idea of having CDI specialists accompany physicians on rounds and other activities to ask questions at the point of care if necessary.

While the concept has merit, professionals agree there will be hurdles and obstacles to effectively implementing such an initiative.

“There can be friction. The doctors are resistant to having one more person ask them questions about something they are doing,”  Zentner says. “ In this role, CDI specialists have to understand how to communicate without leading a physician to a particular diagnosis.”

Breuer says to successfully take CDI efforts to this level, it will take a top-down approach where the value of the program is touted by C-level executives and physician champions. “A lot of it has to do with the visibility of the program,”  she notes, adding that physicians need to be educated as to the role of the CDI specialist as a clinically integrated professional as well as the benefits to this approach. “Physicians need to be aligned with the goals of the program. It’s about engaging the physician community and communicating that the metrics are quality driven for better patient care delivery.”

One of the primary challenges to aligning CDI efforts to meet VBP needs is the inconsistency that exists between language used for clinical terminology, documentation, and coding—all of which present variances to the needs of Medicare. Zentner offers an example of a department that reports infections by their definitions. Because CDI and coding definitions are different, the regulations may not line up.

Consider that a patient with a yeast infection is documented and treated. While it is coded and reported as such, the infection control department does not report it because yeast infections do not fall into their reporting requirements.

This inconsistency will lead to a discrepancy in reporting systems, Zentner points out. “This speaks to the meaningful use of the data we gather which drives quality,”  she notes. “It has to mean the same to everyone or it doesn’t match. This example shows how two departments, infection control and coding, have variable definitions for the same thing and their reporting is conflicting.” 

The goal of CDI needs to focus on getting the language clinicians speak to mean the same thing to coders and allow them to report codes to the highest level of specificity, says Zentner. “That level of quality is our challenge,”  she notes.

Accomplishing this weighty task in a small facility can be challenging at best, according to Stavely, who notes that “in most facilities, there is a premium on good CDI specialists.”  Heading up the program at the 200-bed Jennie Stuart Medical Center with limited resources, Stavely knew it would take months to start an effective program and find qualified personnel. “You either need a supercoder with clinical knowledge or a good nurse with coding experience. CDI is really a combination of that clinical and coding expertise,”  she says.

To get the program off the ground last December, Stavely turned to technology and automation to jump-start the initiative and as a means to bring a “ CDI expert instantly into the facility through a Web-enabled interface.”

The technology was able to provide a “universal translator”  across the continuum to help the facility move toward language and requirements that would hold up under Medicare VBP criteria.

While technology will be a solid tool for healthcare organizations to leverage in their quest to meet the CDI challenge, most experts agree that the knowledge base of CDI specialists will have to be elevated to a deeper clinical level.

“When we look for CDI specialists, we generally look for nurses with experience in med/surg because they have seen a wide variety of diseases,”  Zentner notes. “ We want a nurse with a wide range of knowledge in medicine.”

Zentner adds that an HIM professional can also be a solid choice for this position as long as he or she has experience with inpatient coding. “ It would have to be a coder who loves to code, understands the clinical side, and is comfortable talking to physicians,”  she says.

In the near future, documentation and coding will have to revolve around core measures laid out under VBP, according to Zentner. “We want to make sure that what we are picking up in the record will feed into those initiatives,”  she says.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.