November 2016

Great Lengths, Big Trouble
By Juliann Schaeffer
For The Record
Vol. 28 No. 11 P. 22

Prolonged length of stays can devastate reimbursement, making strong clinical documentation a must.

With hospitals pinching pennies in every corner, who can afford to lose thousands of dollars per day in reimbursement for what the Centers for Medicare & Medicaid Services (CMS) deems a prolonged length of stay (LOS)? What factors play into LOS, who determines an appropriate LOS for any given patient, and how can clinical documentation improvement (CDI) programs effectively monitor the issue?

According to experts, it's a multifactorial problem that can't escape a discussion about documentation. And while many believe a successful CDI program can help, it's a problem that CDI specialists can't (and shouldn't have to) fix alone.

A Complex Issue
"With increasing demands on hospitals today and quality measures affecting reimbursement and penalties, LOS is a significant issue," says Jill Lindsey, RN, BSN, CCDS, senior director of consulting and management services at Advisory Board, who notes that documentation can play a large role in effectively justifying LOS.

The other side is also true, says Gerri Birg, managing director of CDI for Huron Consulting Group. While documentation can be used to explain a necessary LOS, other times it's the reason a patient stays too long. "Prolonged stays that are not medically necessary are a very big problem in health care, and a lot of these difficulties stem from inappropriate documentation," she says.

As Birg explains, the parameters that CMS places on LOS demand health care administrators put processes in place with dedicated staff to meet these requirements. In regard to medical necessity, how sick a patient is and the care that's being delivered are two of the main points considered.

Of course, determining what an "appropriate" LOS is for any given patient scenario isn't a perfect science. "It is difficult to talk about an LOS that is too long without first knowing what the appropriate LOS should be," explains Susan Nedza, MD, senior vice president of clinical outcomes for MPA Healthcare Solutions. "So the issue is how best to define the appropriate length of stay for a given patient."

This is particularly critical—and tricky—when trying to predict the appropriate LOS for a patient prior to admission, says Nedza, who notes that this is an evolving issue within a health care system that's in flux. "It's a critical issue in the new world of value-based payment models such as bundled payments where the cost of postoperative care is included in the payment," she says. "For example, an obese 64-year-old patient with insulin-dependent diabetes will most likely have a different appropriate LOS than a fit 50-year-old patient undergoing a knee replacement. If a hospital were to focus on an average LOS model, it is likely that the diabetic patient might be discharged early if the postoperative risk of adverse outcomes is not considered."

While Nedza says this would potentially save money on the inpatient stay, the probable emergency department (ED) visits, readmissions, and potential complications in the postacute care period would negate those savings and possibly even cost the hospital more in the end. "The appropriate LOS for the healthy patient might be shorter than the average. Therefore, an extra day in the hospital will have no impact on postoperative outcomes yet will consume more resources than necessary," she explains.

According to John A. Hoffstatter, PA-C, MS CIS, PCMH CCE, delivery director, clinical advisory services for CTG, some hospitals may be doing a better job of identifying higher-risk patients and the items that lead to longer hospital stays. Yet at the same time, he contends there hasn't been significant progress made toward eliminating those factors—such as social determinants of care and postdischarge placement needs—that are large contributors to prolonged hospital stays. "So I am not sure we have gained much ground overall, unfortunately," he says, noting that many of these factors are multifactorial and thus don't lend themselves to simple solutions.

While LOS can be a problem in any size system, Tammy Combs, RN, MSN, CCS, CCDS, CDIP, director and lead nurse planner of HIM Practice Excellence for AHIMA, says large organizations with complex patient needs are generally at a higher risk since there are greater care requirements for that patient population.

A hospital's location also plays a significant role. "Hospitals that serve populations that have more challenging social determinants of care will have larger struggles and demands on resources than others who might have fewer issues," says Hoffstatter, noting that economics, education, lifestyles, stability, and environmental factors all can potentially affect a hospital's patient population and thus LOS.

"The big causes of prolonged LOS include comorbidities, complications, and discharge placement/environmental needs," he adds. "The longer a patient stays in the hospital, the higher the risk for the patient. Prolonged hospitalization leads to additional exposure to potential resistant pathogens, opportunities for medication and operational errors, and complications to comorbidities."

Lindsey succinctly illustrates the issue of how a hospital's patient population—and thus LOS—can be dictated in part by its location. "Consider this [theoretical]: You have one hospital in Beverly Hills and another in downtown Oakland. Which one do you suspect will have a longer length of stay? Oakland, of course. Why? Because of its population," she says.

Because Oakland likely has a larger homeless population with compounding issues such as malnutrition, drug addiction, and/or psychological conditions (many of which may have been left untreated for some time), more excessive workups are likely necessary, leading to a longer LOS. "It is also much more difficult to discharge patients who have limited to no insurance and have nowhere safe to where they can be discharged," she says, noting that a lack of resources as well as various discharge planning considerations can also factor into a lengthy LOS.

Start With CDI, Then Documentation
According to Combs, many organizations have implemented initiatives to address prolonged stays that identify the geometric mean LOS (GMLOS) associated with each diagnosis-related group (DRG) concurrent with the admission. Taking into consideration complications and comorbidities (CCs) or major CCs (MCCs) can increase the relative weight and GMLOS in many of the DRGs, she explains.

Combs says CDI professionals are in a particularly relevant spot to address this issue. "Whereas a case manager reviews records for medical necessity and discharge planning, the CDI professional reviews for high-quality clinical documentation," she says. "Many CDI programs review the patient records concurrent with the care and assign working diagnosis codes and DRGs to the patient's case. If the CDI program can share the assigned DRGs with the case managers, they can begin to identify the appropriate needs of the patient.

"Let's say, for example, a patient has been in the hospital for five days and the working DRG has a GMLOS of only three days," she continues. "The CDI professional can review the record for CCs and/or MCCs to help identify and accurately recognize why the patient is still in the hospital."

What CDI specialists may find more often than not is a problem that could be solved by better documentation. "Many times, the inaccuracy in documentation is due to a lack of specificity for a diagnosis," Combs says. "For example, a typical diagnosis seen in the inpatient setting is congestive heart failure (CHF). If the provider just documents CHF without documenting the type of CHF, it does not meet the requirements of a CC. However, if they add the type—systolic or diastolic—to the documentation, it can now be identified as a CC. If the CHF patient has an exacerbation of the disease plus the exacerbation and type are documented, it then becomes an MCC."

In addition, Hoffstatter says specific "assumed" actions and/or diagnosis are not always recorded, creating another area of concern. "For documentation, many of the 'understood' or 'obvious' conditions are not explicitly recorded, which can lead to denials or skewed estimates of stay," he says. "Common items include postoperative complications (not documented, but assumed by diagnosis), anemias (requiring transfusion), or electrolyte disturbances. By documenting actions or treatments, many times it is assumed the diagnosis is known and not always explicitly documented. Consistency of documentation for actions taken for unexpected results or complications should also be recorded regularly."

Conversely, when providers capture the most specific principal diagnosis as well as all secondary diagnoses (including chronic conditions), it allows for a more accurate translation of the patient's complexity into codes, says Jennifer Eaton, RN, MSN, CCDS, director of inpatient CDI for Enjoin.

Lindsey agrees, noting that focusing solely on a patient's acute condition can unknowingly skew LOS estimates. "Chronic conditions are equally important to document as they mostly fit into the requirement of reporting secondary conditions," she says. "Chronic conditions are commonly those that may impact a DRG and increase the LOS."

Indeed, by using documentation to better tell a patient's story, Hoffstatter says hospitals would be much better positioned. "Documentation should document not only the important diagnoses, treatments, and actions but also ancillary activities and planning," he says. "Too often CDI focuses on documentation for the sake of maximizing revenue reimbursement, but it should also include appropriate interdisciplinary communication."

For example, take coordination of discharge planning, an area that can contribute to delayed or prolonged hospital stays. "With the higher-risk patients, the multidisciplinary team involvement can get complicated very quickly, and coordination between providers as well as outside resources becomes essential to efficient discharge planning," Hoffstatter explains. "Efficient discharge planning helps eliminate prolonged hospital stays. Identifying the need for these conversations early in the care and providing consistent and regular documentation will help the multidisciplinary care team be more effective and eliminate needless delays in discharge."

A Proactive Approach
To best monitor this issue, Combs says organizations can implement several processes to detect their LOS metrics, including benchmarking against similar organizations, assigning working DRGs during the concurrent stay, and beginning discharge planning early within the admission.

A strong understanding of clinical risk allows providers to predict the appropriate LOS for specific procedures and patients, says Nedza, who notes this can be done for patients undergoing both elective and emergent surgery. The key is identifying a predicted risk-adjusted LOS for all patients.

But more important than specific procedures is the timing. "Organizations need to be proactive in monitoring higher-risk patients and identifying best-practice standards and protocols," Hoffstatter says. "You can get where you have been retroactively, but to move the needle you need to have processes in place when these patients are admitted."

To that end, he mirrors Combs' assertion that discharge planning should start on admission and be on the staff's mind throughout the hospital stay, not just the last few days. "Communication with the entire care team needs to be done frequently and documented appropriately so there are no ambiguities about who is waiting on what or who is responsible for what aspect of release," Hoffstatter says. "Consistency of that documentation is key to following best practices."

Besides, waiting until a claim is denied is not only more difficult to reverse but also time-intensive, Lindsey says. Tracking and trending LOS can help avoid this on the front end.

By trending LOS data by MS-DRG, provider, or specialty group, Eaton says organizations can identify the areas with the greatest variance between actual and expected LOS. "By being proactive and facilitating data transparency, organizations can get ahead of the denial curve by promoting recognition of LOS variances internally, getting to the root cause of the issue, and, finally, developing a project plan to address the opportunities and ensure ongoing monitoring of improvement efforts," she says.

According to Birg, the end goal should be having a process in place that prevents claims denials from ever happening in the first place. "The goal is to completely move away from retrospective models and processes by looking at patient data in real time and concurrently across the care team," she says. "Many of our clients and partners are pulling LOS issues to the concurrent side and putting processes in place to manage them so they don't experience denials and that when they do occur, their organizations are prepared to efficiently deal with these exceptions.

"The secret sauce is having good processes in place and identifying patient issues concurrently—what that patient's length of stay is and how you will manage care through their stay—so you are not looking at denials later down the line."

Beyond CDI
While Eaton says CDI programs can play an integral role in LOS optimization, she notes that they're not the only players in the game. "Collaboration with case management (CM) and utilization management (UM) on certain levels is key," she says. "The CDI program can offer a valuable piece of information, which can aid CM/UM in prioritizing and anticipating LOS challenges: the concurrent MS-DRG and associated GMLOS. But we also know that the concurrent MS-DRG can evolve throughout the patient's stay. By collaborating with CDI, CM/UM will realize the benefit of an accurate, daily snapshot of the expected LOS based on current documentation."

In a similar vein, Eaton says a CDI team—with help from providers—can have a direct impact on expected LOS through MS-DRG optimization. "By understanding common documentation gaps and query opportunities for the organization, the CDI specialist can query and educate the providers on the need for additional specificity in the medical record, thus leading to more accurate capture of chronic and acute conditions, which could result in a more accurate MS-DRG and associated GMLOS for the patient," she says.

Hoffstatter agrees, noting that a well-documented program consistently applied across providers is critical to effective LOS management. "Having everyone from the clinical, financial, and care team on the same page for expectations of treatment and documentation will help eliminate much of the variation and outliers that are often the cause of prolonged stays," he says. "Consistent documentation facilitates efficient communication."

Huron Consulting Group encourages CDI specialists to be "the manager of the medical records" in order to stay on top of documentation and thus LOS. "In that review from the CDI specialist, the medical necessity should not be in question and should be justified by collaborating with the case manager and all relevant clinicians," Birg says. "If you have a patient and aren't sure if they are meeting medical necessity, you should have a system in place to identify that gap as early on as possible. If you don't, you'll have to talk with the doctor and reverse the admission or find out if they should be in observation."

How does the ED factor into the LOS equation? According to Birg, any comprehensive CDI program should begin here. "The ED is where there can be trouble in meeting medical necessity," she explains. "When a patient is in the ED, they are likely in an acute state and will become an admission. All diagnoses need to be captured throughout, so it can be transferred to the physician. CDI in the ED has become a way to best ensure that the entire care team is looking at a comprehensive continuum of care."

According to Nedza, a board-certified emergency physician and informaticist, a hospital cannot address LOS without tackling disposition. "I often believed that I could predict which patients would require a prolonged course of care," she says. "Unfortunately, that was often based on limited knowledge of postdischarge risk of adverse outcomes. Newly developed models for supporting appropriate emergency department disposition that include risk factors such as 'does the patient live alone?' are more sensitive to identifying those who will have a poor outcome or require a later hospitalization if discharged home. But this points to a fact with which many policymakers struggle."

Nedza contends that when an emergency visit results in a readmission, it's not necessarily the fault of the ED staff—the disposition home may not have been safe for the patient. "EDs serve as an important site in the continuum of care where early recognition of issues and emergent diagnosis and treatment can save money and prevent adverse events in the long run," she says. "For hospitals beginning mandatory participation in CMS and private payer alternative payment models, appropriate LOS and appropriate disposition will define success."

Although many CDI departments are often understaffed, Lindsey says having a CDI specialist in the ED could lessen any LOS issues. "Getting CDI to round in the ED or assigning a CDI specialist to reside in the ED would be an incredible step in the right direction, as CDI would be present during those critical first hours and able to assist in capturing accurate documentation to represent the patient's condition fully," she says.

Communication and Consistency
While many health care organizations are cash-strapped, Birg believes CDI is a worthwhile investment, particularly when it's used to address prolonged LOS. "It can be challenging to allocate staff to function in these roles and ensure you have enough staff that can meet the parameters that CMS has put in place," she says. "CDI takes such a high focus and high skill set for individuals to understand the methodologies that need to be put in place. But when this focus can be maintained, the rework and hassles associated with denials can be eliminated and dedicated staffing can pay for itself."

By implementing CDI programs, Combs says organizations can feel confident that their clinical documentation will be a true reflection of the care rendered. "This not only helps address the length-of-stay concerns but also supports accurate quality scores, appropriate reimbursement, and, many times, a reduction in the denial rate," she says.

Still, the onus shouldn't fall on CDI's shoulders alone, Eaton says. "CDI cannot solve LOS challenges alone," she says. "Like most challenges, LOS optimization is best addressed from a collaborative standpoint. Data accuracy and transparency as well as creation of a sense of awareness for the physicians are key. Organization leadership should also set clear expectations related to engagement in LOS improvement efforts."

Communication across departments plus consistency is key, Hoffstatter says. "CDI has to bring together coding, compliance, clinical, financial and other ancillary care team members. It is important to have consistency across each discipline and each discipline needs to have an understanding of the other areas and roles," he says.

In fact, it's this lack of cooperation that causes many CDI initiatives to fall short. "The most successful CDI programs have been able to bridge the gap so that providers understand the coding world of how they do their job and what key documentation they require, and the coders understand how the provider mind works and how they approach patient care," Hoffstatter says. "The narrower that gap of understanding becomes, the better CDI efforts your organization will have."

— Juliann Schaeffer is a freelance writer and editor based in Alburtis, Pennsylvania.