From my experience, DRG validation is about more than just billing. Ultimately, it’s about ensuring the patient’s clinical story is adequately reflected in the documentation and codes. This alignment is critical for several reasons:

• Accurate Reimbursement: As physicians, we know that the complexity of our patient’s conditions is only sometimes fully captured in the initial coding. Additionally, hospitals can lose substantial revenue when documentation doesn’t reflect the actual severity of illness.
• Reducing Denials: Denied claims place a significant administrative burden on hospitals and clinicians. Validating DRGs ensures that the documented and coded are clinically valid and aligned with coding guidelines, reducing the risk of costly denials.
• Compliance and Audit Readiness: Physicians are held to high standards of care and documentation. A robust DRG validation process helps ensure compliance with coding guidelines, reducing the likelihood of audits and penalties related to high-risk DRGs.
• Quality Measure Performance: Many hospital quality measures such as those within the Center for Medicare and Medicaid Services (CMS) value-based purchasing measures are based entirely on the coded record rather than clinical outcomes. However, this discordance can result in low quality measure performance if the coded record is not an accurate and complete picture of the patient’s conditions and course. 

The most successful DRG validation efforts involve collaboration between multiple teams. CDI specialists, coding professionals, and Physician Advisors each play a vital role:

• CDI Specialists: With their clinical expertise, CDI teams help ensure documentation accuracy and clinical validity. They often identify documentation gaps that can be corrected before coding occurs.
• Coding Experts: Coding professionals ensure the codes applied are accurate and in line with current regulations. They bridge the gap between clinical documentation and the billing process, ensuring that the hospital is reimbursed appropriately. 
• Physician Advisors: Provide additional clinical insight, and a unique perspective needed to ensure that the DRGs accurately reflect the patient’s clinical condition. Our involvement often helps resolve clinical documentation discrepancies, improve queries, and provide necessary education to achieve more accurate coding and improved compliance.

CDIs and coders review cases concurrently, but an additional second-level review may be valuable for certain DRGs. Analogous to clinical workflows, redundancy through collaborative efforts—such as two nurses verifying a high-risk medication dose—helps reduce clinical errors. Although multiple checks within CDI and coding are not always feasible, applying this concept can reduce revenue leakage and improve compliance by ensuring that the coding and documentation in certain cases are accurately reflected in the claim codes

At Brundage Group, I’ve been proud to be a part of a team of CDI, coding professionals and Physician Advisors that have delivered exceptional results through our DRG Validation Reviews:

For Physician Advisors like me, being actively involved in DRG validation has allowed me to bridge the gap between clinical care and the administrative side of healthcare. Moreover, it’s not just about ensuring the hospital gets paid; it’s about ensuring that the patient’s story is accurately documented and that we, as clinicians, are correctly credited for the complexity of the care we deliver. 

If you’re a Physician Advisor or hospital leader, I strongly urge you to participate actively in DRG validation. The impact goes beyond finances—it ensures compliance, reduces denials, and improves the overall quality of care.

By Cheryl Ericson, RN, MS, CCDS, CDIP

Gone are the days when Clinical Documentation Integrity (CDI) was referred to as a “program.” Today, CDI Departments have become mainstream. They are no longer a supplemental business function as hospitals without a robust CDI department cannot keep up with their peers. As an integral part of the revenue cycle, CDI activities must be tied to organizational metrics in meaningful ways that identify success and improvement opportunities.

Traditionally, when hospitals faced economic hardships, they would set goals to either grow revenue or cut costs. A favorite metric of hospital leadership when tracking revenue expectations within the inpatient population has been case mix index (CMI). Often leadership would set year-over-year goals of increasing the CMI. In the early days of CDI, there was a lot of opportunity and CDI departments would be credited with “finding” millions of dollars of incremental revenue through an increasing CMI even though there are many factors that impact CMI beyond CDI activities.

Fast-forward to the COVID pandemic, when CMIs peaked because only the sickest patients could access inpatient care. But there was also an important lesson to be learned during COVID regarding CMI. A high CMI was no guarantee of profitability. MS-DRGs are a classification scheme comprised of clinically similar patients as determined by the principal diagnosis, who are expected to consistently use similar amounts of hospital resources. It was designed to cover routine costs like room and board, nursing care, diagnostics, treatment, and ancillary services. Patients who need additional healthcare resources are identified through secondary diagnoses classified as complications/comorbidities (CC) and major complications/comorbidities (MCC). When a CC or MCC is present on a claim and not designed by the Centers for Medicare and Medicaid (CMS) as a Hospital Acquired Condition (HAC), the hospital gets paid a higher rate because the patient requires more hospital resources.

The Medicare Severity Diagnostic Related Group (MS-DRG) reimbursement methodology is a prospective payment system. The significance of this should not be overlooked. Hospitals provide services in good faith under the MS-DRG system expecting future payment that reflects the billed MS-DRG. Astute hospitals have always tracked both the billed CMI as well as the adjusted CMI. The adjusted CMI is based upon payments received rather than what was billed. The importance of monitoring the adjusted CMI cannot be overstated in today’s healthcare environment where payer denials are ever increasing.

CDI activities affect not only the billed CMI but also the adjusted CMI. As hospitals look to maximize revenue opportunities there may be additional pressure on CDI departments to increase CC and MCC capture rates and CMI, but this only tells half the story. However, a better way to monitor the effectiveness of CDI efforts is to examine how CDI efforts contribute to the adjusted CMI. This is where revenue leakage is occurring. The goal has always been for CDI activities to support accurate billing that reflects the acuity of the patient population. Though all denials are not justifiable even on appeal, the result is still an inaccurate bill. The hospital is “losing” expected revenue. Tracking the adjusted CMI helps an organization create more of a realistic expectation of incremental revenue opportunities, especially when there is no guarantee that CMI will continue to increase.

Tracking the right metrics allows hospital leadership to better measure the success and shortcomings of CDI efforts. One of the metrics that hospitals should track is the percentage of cases reviewed by CDI staff that results in a denial, especially when a clinical validation denial affects a diagnosis added by a CDI query. Because submitting “accurate” bills can reduce revenue leakage and the administrative costs associated with appeals, it is in every hospital’s financial interest to track the impact of CDI and Coding activities on the billing process. This is not to imply that individual CDI and Coding professionals should be reprimanded when a denial occurs on a claim they worked; however, it is important for CDI and Coding professionals to receive direct feedback about how their work is affecting the overall financial health of the organization so adjustments can be made as needed to minimize lost revenue.

Because the lifecycle of a claim can be so long, it can be beneficial to use a proxy to audit inpatient claims prior to their submission. Many organizations have a second level review process or internal audit process, but it is often more effective to have an objective third party conduct these second level reviews and provide constructive feedback on problematic trends. When considering a vendor to perform these prebill audits, it is best to consider one who has experience in appealing DRG and clinical validation denials because they are more likely to understand industry trends that contribute to revenue leakage even if it has yet to reach your health system.

Though it is unrealistic to expect 100% accuracy- as some payers may have unreasonable expectations – improvement is always possible. Tracking “clean claims” has always been a metric in the outpatient setting and a measure of success for registration, insurance verification, and other early revenue cycle departments.

As we celebrate Clinical Documentation Integrity (CDI) Week September 16 – 20, it’s the perfect time to spotlight CDI’s vital role in healthcare. CDI is not just about accurate documentation; it’s about assuring that hospitals are appropriately reimbursed for their care, reducing compliance risks, and supporting high-quality patient care. One of the most critical areas that CDI professional impact is Diagnosis-Related Group (DRG) assignment. Want to learn how CDI and DRG validation work together to compliantly capture earned revenue?

CDI departments are the backbone of accurate clinical documentation, ensuring that the medical record fully captures the clinical scenario in terms that accurately reflect patient acuity within ICD-10 nomenclature. This accuracy is essential for correct DRG assignment, as DRGs categorize patients for billing purposes. Incomplete or imprecise documentation can lead to incorrect DRG assignments, potentially affecting hospital reimbursement and financial health.

CDI specialists help optimize DRG assignments by identifying clinical indicators associated with undocumented diagnoses, ensuring hospitals receive appropriate reimbursement for care delivered. This optimization prevents the pitfalls of under coding, which can lead to lost revenue, and over coding, which can result in compliance risks. Accurate DRG assignment is critical to aligning hospitals’ reimbursements with the quality of care delivered, ensuring the financial sustainability of healthcare organizations.

One of CDI’s core functions involves working closely with physicians to clarify vague, incomplete, or ambiguous diagnoses. This clarification ensures that all relevant conditions, including comorbidities, are accurately documented. Proper documentation of these details is crucial for DRG assignment, as the billed DRGs is often determined by secondary diagnoses that reflect the complexity of care. This process helps ensure that hospitals are reimbursed appropriately based on the resources used to treat the patient.

CDI isn’t just about financial outcomes—it’s also about compliance. Clinical validation has become a critical activity performed by CDI professionals.  Performing clinical validation reviews minimizes the risk of DRG downgrades during audits and helps prevent claim denials. Proper CDI practices ensure that the documentation can withstand scrutiny from payers and regulatory agencies, reducing compliance risks and supporting a seamless revenue cycle.

Effective CDI practices lead to comprehensive clinical documentation, directly influencing accurate DRG assignments, optimizing reimbursement, and ensuring compliance. A strong CDI department supports accurate code assignment, which in turn, leads to accurate DRG assignment that minimizes financial losses and maximizes performance on outcome quality measures.

When scouting for a stellar CDI specialist, you seek someone who will drive excellent patient outcomes. This critical role requires specific skill sets: unmatched expertise in clinical documentation integrity (CDI) and a continuous commitment to learning.

The right candidate can transform your hospital by improving accuracy and efficiency, which is essential to keeping pace in today’s rapidly changing medical field.

When seeking a CDI Specialist, assess qualifications and certifications closely. Strong candidates often hold the Certified Clinical Documentation Specialist (CCDS) credential offered by the Association for Clinical Documentation Integrity Specialists (ACDIS) or the Certified Documentation Integrity Practitioner from the American Health Information Management Association (AHIMA). These credentials illustrate knowledge in areas such as medical terminology, anatomy, pharmacology, chronic condition management, and coding guidelines. A nursing degree isn’t universally required, but it may be favored by some hospitals.

Remember that potential hires should manage their workload independently while communicating effectively via virtual channels when required to do so. Qualities demonstrating adequate adaptability are key within dynamic roles such as those found within healthcare recruiting firms specializing in sourcing skilled personnel for hospitals. Coexisting harmoniously alongside physicians/colleagues is necessary, considering they’re integral partners in your mission towards efficient documentation that supports hospital revenue.

When looking for a CDI professional, consider their experience. How well they navigate the complexities of clinical documentation shows expertise and understanding. You want someone who can work with multiple personalities across different medical disciplines without any significant problems.

A potential hire should exhibit fluency in managing both data algorithms and provider reimbursement issues, areas highly critical to your operations’ efficiency. One crucial aspect you need to focus on is whether candidates have an acquaintance or are familiar with working with “CDI physician champions.” Their role revolves around improving documentation, which is important as it bridges the gap between other physicians and colleagues within an organization.

Finally, observe how effectively they communicate virtually; this indicates their ability to function independently when needed without much supervision from higher-ups while maintaining professional decorum at all times, even under pressure-filled circumstances.

Remember: You’re not only hiring them because of their competence but also due to their being a team player, so choose wisely!

When hiring a CDI professional, understanding hospital practices and procedures is crucial. Deep knowledge of revenue cycle processes goes beyond the textbook; it’s about practical application. You rely on this professional to decode medical records to support accurate coding that can impact both performance on quality-of-care indicators and hospital reimbursement.

The CDI professional need proficiency in determining when a diagnosis can be reported on a claim as well as interpreting provider documentation into accurate diagnosis codes. This role should comprehend various diagnoses thoroughly; identifying subtle nuances between general conditions versus more specific ones when translating them into precise codes is paramount.

Moreover, they must exhibit adeptness at using critical thinking skills to pinpoint gaps in documentation that might demand clarification; a pivotal skill set indeed! The ability to facilitate seamless connections among patients’ health status records further underlines their competency level; the evidence of excellent collaboration capabilities is undeniably vital here.

When seeking a CDI specialist, professionalism ranks high on the list. This trait encompasses an individual’s attitude towards their work, showing respect for hospital policies and adhering to industry standards. Reliability is another critical factor; you need someone you can count on to consistently deliver excellent results.

A reliable worker won’t offer excuses but solutions; instead, they’ll tackle challenges head-on while upholding quality. Availability shouldn’t be overlooked either; the healthcare landscape shifts continuously, sometimes by the minute! So, it helps if your chosen professional has flexible hours that complement this demand-driven sector.

Remember these three attributes: professionalism, reliability, and availability as you navigate through your hiring process for a new CDI specialist.

In your search for a CDI specialist, consider their adaptability. The work environment of healthcare is ever-changing, often requiring quick and on-the-spot adjustments to different situations. An ideal candidate should possess the agility to swiftly decipher complex medical data and translate it into reportable diagnoses.

Their capacity for flexibility can greatly impact their efficiency when facing novel circumstances brought about by rapidly evolving health scenarios or technology updates. Encourage candidates to share instances where they’ve had to adjust strategies quickly without compromising accuracy or quality during interviews.

Remember that coping with unpredicted changes is not only crucial but intrinsic within this role, as it aligns directly with the interplay between patient documentation and code assignment, a critical connection point overseen by all successful CDI specialists.

Establishing a robust network within the CDI community plays an integral role in hiring quality personnel. Embrace frequent participation at industry events, seminars, and conferences to forge valuable connections. Having your presence felt among this circle not only enhances your reputation but also gives you direct access to a pool of potential candidates.

Consider actively involving yourself on online platforms dedicated to CDI professionals. You can gain insights into the latest trends or participate in engaging discussions that might open doors for talent acquisition. Moreover, these networks are often treasure troves when it comes to spotting professionals demonstrating a keen interest and deep knowledge about various facets of CDI.

Lastly, having regular communication with educational institutions offering specialized courses directly or tangentially related to CDIs can help you scout fresh talent right from academia itself. In sum, understanding its significance is mandatory as networking isn’t merely gathering contacts; it’s all about establishing relationships conducive to recruiting ideal individuals best positioned for success.

Evaluating a potential CDI specialist is more than just reviewing credentials. Examine their comprehension of clinical matters, regulatory policies, and coding expertise. Assess their communication skills as well; they will be interacting extensively with the healthcare team at your organization.

Reducing denied claims and underpayments is a vital part of Revenue Cycle Management (RCM). The leadership of most hospitals knows just how essential Clinical Documentation Integrity (CDI) is to the clinical revenue cycle. A robust CDI department ensures hospital inpatient services are appropriately reflected in the health record so they can be accurately coded and billed.

The quality of clinical documentation can impact both hospital revenue and performance on quality measures. Encouraging providers to document a detailed and precise description of the clinical scenario can ensure the medical claim correctly reflects the gravity and complexity of cases being treated, paving a path towards legitimate higher reimbursements. Clinical Documentation Integrity (CDI) departments can lead to a more accurate representation of case mix indices. These numbers represent average illness severity amongst your patients: high indices are an indicator of complex cases that should rightfully earn higher reimbursement.  Enhancing Clinical Documentation Integrity (CDI) is vital for your revenue cycle.

With specialized education in this field, clinical documentation specialists play an integral role. They’ll ensure integrity by bridging communication gaps between providers and coders. Let’s delve into how CDI revolutionizes healthcare organizations and its educational requirements.

CDI ensures accuracy in medical records and increases the speed and efficiency of coding. This is a process that can significantly reduce denials. The current changes in reimbursement are causing an increased focus on outpatient settings, prompting facilities to think about employing remote support solutions. To make sure that these new professionals meet the clinical requirements related to classification systems such as MS-DRG assignments, it is essential to have a thorough understanding of them.

Additionally, they need to be able to analyze patient documentation critically to ensure an accurate representation of the patient’s severity or risk profile. These are part-and-parcel skills that are required by those who strive for nothing less than excellence.

To maximize reimbursement, you must focus on clinical documentation improvement. Poorly noted provider entries can lead to value-based penalties.

Take Medicare, for example. It has been promoting better clinical notes among fee-for-service payments via instruments like MS-DRGs since 2007. The goal is a shift towards reimbursing hospitals more if they treat high-risk patients.

Failing to document MS-DRG and support codes can dent your revenue. This error often arises from staff not fully grasping robust documentation practices, an issue reported by two-thirds of CDI specialists in a recent survey. But how does good CDI bring about clear benefits?

According to Black Book Market Research’s findings in 2016, a majority of hospitals that employed solid Clinical Documentation Improvement (CDI) programs saw their revenues increase substantially. Some healthcare institutions increased their revenue by as much as $1.5 million.

The success of these CDI measures is attributed to the successful execution of case mix index improvements, which was confirmed by many healthcare finance heads from various institutions across the United States who participated in this research study.

The optimal recording of diagnoses, procedures, or comorbid conditions can profoundly affect care delivery and financial outcomes. The CDI specialist acts as an expert advisor to help ensure staff adhere to essential best practices for clinical documentation.

By properly documenting clinical information, accuracy is maintained, and errors are prevented that could potentially put patient safety at risk or lead to undesired legal action. Their deep knowledge of chart review tactics and coding skills will be instrumental for success.

The CDI specialist doesn’t just work alone. Collaboration is essential to their success. They need to have ongoing conversations with CFOs and other leaders to form clear goals from the beginning. Later, they can use performance indicators such as severity of illness scores and mortality risk to measure the progress.

In healthcare, you can’t overlook advanced analytics’ role in decision-making. Better decisions are possible with clear data insights presented by this technology. Remember, your clinical documentation holds significant potential. Over time, it can become a gold mine for data analysis.

Advanced analytics provides an effective way to extract useful information from large amounts of accumulated patient records. This can help you discover new insights that can be used to increase operational efficiency in your organization, something key in today’s rapidly evolving medical landscape.

Using these tools effectively might seem daunting at first due to the complex datasets involved and varying input data formats, ranging from lab reports to radiology images.

However, don’t let the complexities of large volumes of structured or unstructured health records be a barrier. Powerful algorithms make navigating them efficient and cost-effective. Predictive analytics allow us to forecast future trends based on historical patterns, while prescriptive measures uncover new strategies. There is also potential to explore untapped areas through discovery techniques.

CDI plays a critical role in this management process by ensuring complete and accurate documentation of patient care details. The benefits derived from hiring CDI professionals are plentiful. Such professionals review medical records to gauge severity, acuity, or risk, which helps to optimize revenue streams for improved financial health.

Furthermore, a Black Book Market Research report shows that almost 90% of larger hospitals experienced significant gains once they implemented this invigorated approach toward clinical documentation.

The introduction of remote support positions has the potential to scale up these practices beyond IP facilities. This could encompass outpatient settings as well. This adaptation has become increasingly important in light of recent changes in reimbursement procedures. These procedures emphasize optimal performance across all sectors, such as emergency departments and hospital clinics.

Expanding horizons also means educating staff about thriving documentation guidelines, blending efficiency with quality assurance measures, and robustly catering to rising complexities involved with chronic illness treatments today. Remember, investing time now in managing risks borne out through inaccuracies will help mold safer paths ahead for all stakeholders involved within your system’s ecosystem.

CDI can significantly elevate that aspect. Picture this: CDI bridges gaps between clinical practice and its documentation. Through it, clarity emerges in written medical records about the exact treatment given to patients.

This clear record assists other clinicians when they take over or continue patient care later on. Moreover, by gaining detailed insight into each unique case, proper diagnoses become more precise with less room for error. This is an integral factor, especially under current health reimbursement models focusing on service quality rather than quantity.

This shows how implementing proactive steps like integrating CDI into routine processes can indirectly enhance patient-centered service delivery, which is essential considering today’s competitive healthcare landscape dominated by value-based approaches.

Your healthcare organization thrives when all team members speak a shared language. This unity enables accurate, swift action to help patients in need. Think about introducing regular interdepartmental meetings for better information flow between staff departments or teams working together.

That way, everyone stays on the same page, and medical records become more precise because everybody knows what terminology means across various disciplines. Moreover, consider using digital platforms for record keeping and sharing clinical documentation updates within your institution.

It speeds up processes and reduces the chances of errors! Regular protocol training sessions are also key: they ensure each person understands their role clearly, along with the necessary guidelines applicable to them.

Clinical documentation integrity and improvement, a key service Brundage Group offers, greatly benefits healthcare organizations. It enhances patient care quality and bolsters the financial position of facilities while ensuring compliance with regulatory standards. CDI presents an opportunity for growth; it’s about better understanding your data to facilitate optimal real-time decision-making.

Stepping up your Clinical Documentation Integrity education? Here’s how Brundage Group can help: With a focus on education, our team of expert physician advisors engages physicians in comprehensive training programs for CDI competencies.

This results in higher-quality documentation that accurately reflects patient conditions. As you participate fully, you will gain the skills needed to precisely capture and document patient diagnoses and treatment plans. Such precision is beneficial as it facilitates effective communication among healthcare professionals, substantially improving care coordination.

Moreover, your newly verified knowledge will boost clinical decision-making while diminishing medical errors and enhancing overall patient safety measures and outcomes under your excellent care. Clearer documentation also aids hospitals by allowing accurate measuring and reporting of quality metrics and streamlining performance improvement initiatives for better health service delivery.

Whether you’re a seasoned practitioner or a new clinician exploring this terrain, a specialist like yourself can gain much from improved CDI strategies through dedicated learning experiences.

You’re well aware that our healthcare landscape has many rules, regulations, and compliance requirements. It’s crucial for your practice to stay on top of these ever-evolving standards while delivering quality patient care. Our team can guide you through the complex world of regulatory compliance like seasoned pathfinders with medical backgrounds. We know where potential pitfalls reside! We offer targeted advice designed specifically for those working directly within the sphere responsible for strictly adhering to policy directives from governing bodies such as CMS or private insurers.

We help ensure precise documentation supporting proper coding accurately reflects patients’ complexity levels. This assists in maintaining adherence to pressures from regulators and mitigating audit risks that could potentially damage reputations and negatively impact providers financially. So yes, understanding regulatory compliance isn’t just ticking off checklist boxes; it has real-life implications that touch every aspect of your professional career, even extending beyond financial stability and personal risk management domains.

Brundage Group applies a systematic approach to spot incomplete documentation issues. Our skilled advisors use advanced tools and techniques to thoroughly scrutinize your data and identify gaps in information or inaccuracies that can harm the integrity of records, such as ambiguous diagnoses, insufficiently documented procedures, and missing etiology. Incomplete data disrupts communication between healthcare providers and can also affect billing codes, leading to denied claims or penalties for non-compliance with regulatory standards.

Brundage Group’s consultants possess unmatched expertise on how clinical events should be accurately reflected on paper, enabling better coordination of care while enhancing quality and compliance efforts. We work closely with you to ensure each medical record is complete before being put into the coding workflow. This creates the transparency needed for accurate reimbursement and quality outcome reporting across all departments. Our team helps professionals like yourself understand what they need to look out for when reviewing documents, empowering them through targeted training sessions about proper practices so every detail gets recorded correctly from day one!

As you strive to make the most of clinical coding resources, guidance from an expert can be invaluable. Brundage Group fills that role with technology and education customized to your unique needs. We offer advanced tools designed to track documentation accuracy effectively.

Alongside leveraging this cutting-edge tech platform, we provide detailed insights into utilizing these resources efficiently. Our team delivers specific training sessions directly tailored to physicians’ requirements as well as general ones beneficial for broader hospital staff groups.

With our progressive approach combining human expertise and modern-day solutions harmoniously, achieving improved operational efficiency becomes achievable even amidst evolving regulatory landscapes or emerging healthcare delivery challenges facing today’s hospitals.

Brundage Group utilizes a direct engagement methodology to help enhance the overall understanding of clinical coding best practices. This improved comprehension aids communication between doctors and individuals responsible for accurately recording patient-critical health information, not just meeting compliance mandates. By doing this, the quality of care delivered to patients is improved.

Documentation integrity plays a pivotal role. Brundage Group contributes considerably to this scenario with the help of seasoned physician advisors. We aid you in grasping how thorough and precise clinical documents can boost performance metrics.

Focus here on chronic conditions deserves special mention, as they significantly affect facility-level evaluations like HCC scores or MIPS adjustments. During training sessions, our professionals focus on making physicians familiar with appropriate documenting practices and emphasize their significance related to patient care outcomes and facility revenue perspectives. We take action to improve the accuracy of risk adjustment methodologies—a component crucial for optimized reimbursement patterns—for every complex case that healthcare providers handle.

To enrich the dialogue between physicians and coders, Brundage Group provides interactive training sessions designed to improve mutual understanding of coding rules, link clinical findings with appropriate codes, and capture patients’ illness severity more accurately. Extensive efforts go into simplifying coding language for doctors while giving a deeper insight into medical practice standards for coders, resulting in a shared vocabulary that bridges gaps across different health roles. We believe robust interaction supports accurate documentation, improving patient care quality.

With common ground established through these trainings, communication barriers dissolve, leading to effective cooperation among team members. Remember this: good conversation is powerful; it fosters unity within your team and positively impacts essential aspects like financial stability and compliance adherence.

When you choose Brundage Group, you’re signing up for expert guidance in Clinical Documentation Integrity. Our experienced team provides insightful education to improve clinical outcomes. We also ensure accurate reimbursement while minimizing compliance risks through rigorous auditing procedures.

Therefore, if achieving a gold standard in healthcare services is your aim, let Brundage Group assist you on this quality improvement journey.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

CDI and coding professionals should consider the totality of the record when determining if a diagnosis is reportable.

Some diagnoses can be validated with diagnostic evidence e.g., x-ray, CT scan, ultrasound, etc. while other diagnoses are based on a provider’s experience and patient presentation. Many clinical documentation integrity (CDI) and coding professionals rely upon the Official Coding Guideline for uncertain diagnoses (Section III.C) for these types of diagnoses which states,

“If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.”

But what CDI professionals may not be aware of there are several American Hospital Association (AHA) Coding Clinics related to this coding guideline that clarify what terminology is considered “uncertain.” Why is this important? Because providers usually don’t document uncertain diagnoses at the time of discharge unless coached to do so. It is also important to note that the above uncertain diagnosis guideline only applies to the inpatient setting because the outpatient setting also has an uncertain diagnosis guideline (Section IV.H) that states,

“Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” “compatible with,” “consistent with,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.

This context is needed to accurately interpret AHA Coding Clinic Advice related to uncertain diagnoses. Because the guideline includes the phrase “other similar terms,” Coding Clinic has been asked about different qualifiers and if their use results in an uncertain diagnosis or not. Consequently, Coding Clinic determined “concern for is a term that should be interpreted as an uncertain diagnosis and coded following the guideline for ‘uncertain diagnoses’ in the inpatient setting (Issue 1, 2018);” and appears to be “fits the definition of a probably or suspected condition that would not be coded in the outpatient setting (Issue 3, 2009).”

However, the Issue 3, 2009 AHA Coding Clinic also states, “when the provider documents ‘evidence of’ a particular condition, it is not considered an uncertain diagnosis and should be appropriately coded and reported in the outpatient setting.” Some may think this advice only applies to the outpatient setting, but that would be an inaccurate interpretation because the above Coding Guidelines demonstrate that the outpatient coding guideline is much more restrictive than the inpatient coding guideline.

Uncertain diagnoses cannot be reported in the outpatient setting but can be reported in the inpatient setting “if documented as such at the time of discharge.” If “evidence of” is not considered a qualifier that results in an uncertain diagnosis in the outpatient setting, then the same would be true for the inpatient setting.

Why does this matter? Because if a provider documents “evidence of gram-negative pneumonia” or some other clinical diagnosis in a progress note, and the diagnosis is supported with clinical evidence, and meets the definition of a reportable diagnosis or principal diagnosis; the diagnosis can be reported.

In my opinion, it is much more likely a provider will document “evidence of” a diagnosis in a progress note, than qualify a diagnosis as uncertain at the time of discharge. I also feel like use of “evidence of” gives the provider a little bit of wiggle room when they are making a clinical diagnosis, one that cannot be easily validated by diagnostics, but is based on presenting signs and symptoms as well as response to treatment.

There are several instances when providers may rely upon clinical findings to either make a diagnosis or provide more specificity about a diagnosis e.g., specifying the type of pneumonia, ischemic stroke, metabolic encephalopathy, etc. and use of “evidence of” may be appropriate due to a lack of diagnostic evidence. Providers aren’t required to prove a diagnosis beyond a shadow of doubt for it to be reportable, but many are hesitant to document a diagnosis until they reach a degree of certainty due to the potential for liability.

Each provider will have their own threshold of how much clinical evidence they need to make a definitive diagnosis, which is allowable under Coding Guideline 19 that states,

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider.”

The guideline doesn’t say there must be diagnostic evidence to support a reportable diagnosis, only that the provider must document that the condition exists. Of course, we know there must be clinical evidence to support every reported diagnosis to avoid a clinical validation denial, but we often forget the importance of patient history and presentation. For example, providers in the office setting will often make a diagnosis of pneumonia without a chest x-ray to confirm the diagnosis.

Just to be clear, a diagnosis qualified with “evidence of” will also need to be clinically valid, but the validation may be, for example, the presence of pneumonia, but not the causative organism. In this example the use of “evidence of” allows the provider to further specify the type of pneumonia when they are unlikely to isolate the causative organism through diagnostic tests but can make an educated guess about the causative organism based on the patient’s history, presentation, and response to treatment.

Another example is when determining the type of encephalopathy in a complex patient. Rather than documenting “likely metabolic encephalopathy” which can only be reported if documented at the time of discharge, the provider can document “evidence of metabolic encephalopathy” in any note because it “evidence of” is does not make metabolic encephalopathy an uncertain diagnosis. When educating providers about “evidence of,” I also educate them to document if the condition is later ruled out. I find this to be a more successful approach than hoping a provider will document an uncertain diagnosis at the time of discharge.

Additionally, most of us have been inaccurately applying the inpatient uncertain diagnosis guideline which states, “The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.” Use of the word “and” in this guideline implies that all conditions must be met for the Coding Guideline to apply. One of those conditions is arrangements for further workup or observation. If you encourage providers to document uncertain diagnoses at the time of discharge, also educate them document how the condition will be followed up post-discharge.

I’m not sure why many CDI and coding professionals prefer to rely on the inpatient uncertain diagnosis guideline rather than educating providers to use “evidence of” when they lack diagnostic certainty to support an appropriate diagnosis, but I hope this article will encourage more of you to use this approach. I also encourage CDI and coding professionals to consider the totality of the record when determining if a diagnosis is reportable because providers will often copy and paste documentation where a diagnosis is uncertain pending further workup into subsequent progress notes or even the discharge summary making it appear that a diagnosis is still being worked up, but the diagnosis was ruled out or lacks clinical validation to be reported.

Before applying the inpatient uncertain diagnosis guideline validate the diagnosis was not already worked up and ruled out or that there is sufficient clinical evidence for the diagnosis to be reported.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

Is your hospital receiving a high volume of clinical validation denials? If so, you’re not alone.

Clinical validation denials continue to grow in volume and many organizations remain vulnerable to them. Clinical validation was defined with the 2011 Recovery Auditor (RA) scope of work as a separate process from DRG validation, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented.

Does your organization have a clinical validation process in place, and if so, it is as robust as your DRG validation process? If not, why not?

When Coding Guideline 19 for Code Assignment and Clinical Criteria was introduced, there was a corresponding Coding Clinic that included some key concepts related to how this guideline should be interpreted. These included the following:

1. Although ultimately related to the accuracy of coding, clinical validation is a separate function from the coding process.
2. If the physician documents sepsis, and the coder assigns the code for sepsis, and a clinical validation reviewer later disagrees with the physician’s diagnosis that is a clinical issue but is not a coding error.
3. A facility or payer may require a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but hat is a clinical issue outside of the coding system

So, who in your organization is responsible for clinical validation? It is not a coding function, but has your organization embraced it as a clinical documentation integrity (CDI) function and dedicated the resources necessary to develop a robust clinical validation process?

I know many organizations have implemented organizational definitions for diagnoses vulnerable to clinical validation like sepsis, acute respiratory failure, malnutrition and others, but organizational definitions are not enough to create a robust clinical validation process. Ironically, my company often sees clinical validation denials associated with diagnoses that were added through a CDI query at a healthcare organization with organizational definitions.

You see, it starts with fundamentals. What is the goal of the CDI department? Is it really documentation integrity and accurate reimbursement? If so, why as a CDI professional don’t we have a defined processes of what to do when a diagnosis isn’t clinically validated but a code is assigned? Is it enough to query to ask if the diagnosis was ruled out?

There are so many gaps in the clinical validation process on the hospital side that need to be addressed it is no wonder that payers are taking full advantage.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

New codes become effective Oct. 1, 2022.

With the start of fiscal year (FY) 2023 right around the corner, this is a good time for clinical documentation integrity (CDI) professionals update their practices to reflect FY 2023 changes. I’m sure most of you have already downloaded FY 2023 ICD-10-CM/PCS and the Official Coding Guidelines, but there are some other lesser-known resources that can help you prepare for FY 2023.

When you visit the 2023 ICD-10-CM on CMS.gov to get a copy of the FY 2023 ICD-10-CM Coding Guidelines, it is often worthwhile to download the 2023 Addendum. As I prepare for FY 2023, I like to review the ICD-10-CM Tabular List of Disease and Injuries 2023 Addenda. The addenda reveal what changes occurred in the tabular list by each chapter so it is an easy way to find new, deleted and revised ICD-10-CM codes. There is a table that I’ll mention below that also lists new, deleted, and revised codes, but I like to see the changes in the context of the tabular list because then I gain insight into how to properly use the code.

For example, did you know code E87.2 for acidosis has been expanded? Instead of one code for all types of acidosis, E87.2 has been expanded to four different codes and these include the following:

• Code E87.2 acidosis has been deleted
• E87.20 is a new code for acidosis, unspecified but still includes lactic acidosis NOS and metabolic acidosis NOS
• E87.21 is a new code for ACUTE metabolic acidosis that includes acute lactic acidosis
• E87.22 is a new code for CHRONIC metabolic acidosis that includes lactic acidosis with a code first note for the underlying etiology, if applicable
• E87.29 is a new code for other acidosis that includes respiratory acidosis NOS

What I find most interesting is the addition of acuity with the diagnosis of acidosis. Code E87.2, which included both acute and chronic acidosis was classified as a complication (CC), but I wonder if differentiating between acute and chronic acidosis will eventually result chronic metabolic acidosis being removed from the CC list. Hold onto that thought as I tell you a way to check out if these new codes are classified as a CC or not.The other must have resource from the 2023 ICD-10-CM CMS.gov webpage is the 2023 code tables, tabular and index. I like to keep a PDF copy of the alphabetic index and tabular list so I can quickly look up diagnoses by either description or ICD-10-CM code. Again, some of you may find it faster to use a grouper, but with the type of work I do, I often what to know every term associated with a particular ICD-10-CM code. Let me give you an example, there are many “other” and “unspecified” codes, and the tabular list does not include all synonyms, so I often search the alphabetic index by that particular ICD-10-CM code to find those other inclusive conditions. Let’s say I wanted to know what diagnoses are included in code G92.8 Other toxic encephalopathy. The tabular list only includes toxic encephalitis and toxic metabolic, but when you search the alphabetic index by “G92.8” you’ll find the additional diagnoses of “drug included metabolic encephalopathy,” “Jamaican neuropathy,” “Jamaican paraplegic tropical ataxic-spastic syndrome,” and “heroin vapor leukoencephalopathy” to name a few. The tabular list is not all inclusive of every condition that will map to a particular ICD-10-CM code.The next site I would strongly encourage you to visit is the FY 2023 IPPS Final Rule home page. There are a couple of different references that I like from this site. Primarily, I get my own copy of Table 5, the list of MS-DRGs, relative weighting factors, and geometric and arithmetic mean length of stay. If you didn’t know, the associated relative weights and length of stay are updated annually based on prior year claims. Many organizations have analyst who will compare the current year Table 5 to the prior year Table 5 to identify potential revenue shifts as some MS-DRGs may have lower or higher relative weights compared to the prior year. I like having an electronic copy of the MS-DRGs because I find it easier to search than using a book.

This site is also where you will find the tables that outline all ICD-10-CM and PCS code changes. Table 6A includes all the new diagnosis codes for FY 2023. Table 6J includes ICD-10-CM diagnosis codes classified as CCs in FY 2023. I often focus on tables 6J.1 and 6J.2 because these tables list what codes have been added or removed from the CC list. Similar tables exist to identify these changes among diagnoses classified as MCCs. In a moment, I’ll share another tool where you can also check ICD-10-CM codes against the FY 2023 CC and MCC list.

I often find that a more useful on-going resource, but I start with these lists so I can begin educating my peers and providers about the impeding code changes, so we aren’t caught off guard. For example, as expected E87.2 has been removed as CC, appearing on Table 6J.2 because the code no longer exists. However, the new acidosis codes are all included on Table 6J.1 for additions to the CC list.

ICD-10-CM/PCS MS-DRG v40.0 Definitions Manual page

One of my favorite resources is the ICD-10-CM/PCS MS-DRG v40.0 Definitions Manual. This version will be in effect from 10/1/22 to 3/31/23. Before you think the associated dates are a typo, remember updates now occur biannually. Why do I love this resource? It allows me to quickly research how ICD-10-CM/PCS codes impact MS-DRG assignment. Whether you are new to CDI or a veteran, this website has some great resources to help you understand MS-DRG methodology. For example, did you know MS-DRG v40.0 contains a combination of 73,639 diagnosis codes and 78, 494 procedure codes? The design and development of the diagnosis related group (DRG) reference includes a table that outlines the breakdown of base MS-DRGs.

The ICD-10-CM/PCS MS-DRG v40.0 Definitions Manual lists all the MS-DRGs by Major Diagnostic Category (MDC). Within each MDC the associated MS-DRGs are separated by surgical and medical MS-DRGs. Want to know what ICD-10-CM and/or ICD-10-PCS codes map to a particular MS-DRG? This is the resource for you when you are doing research on the fly or don’t have access to a grouper.

Perhaps the most valuable resource associated with the Definitions Manual is the appendixes. With the start of a new fiscal year, it is often hard to remember which diagnoses are classified as a CC or MCC. Appendix G includes Diagnoses defined as complications or comorbidities, numerical list of ICD-10-CM codes that are classified as CCs. Appendix H includes those diagnoses defined as major complications or comorbidities or (MCC).

Remember those new acidosis codes I mentioned? Rather than having to access all the different tables within the FY 2023 Final Rules page, I find referencing Appendix G a lot easier. A quick search of Appendix G allows me to verify that all the new acidosis codes (E87.20-E87.29) are currently classified as CCs in FY 2023.

I hope you find these resources as helpful as I do as you prepare for FY 2023.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

Documenting a diagnosis in the health record extends beyond its impact on reimbursement and quality-of-care measures. It is also critical to patient safety.

As a clinical documentation integrity (CD) I professional with a nursing background, since I’m no longer at the beside, I often feel disconnected from the human aspect of my work. I know I am doing important work to ensure healthcare data is accurate, but am I really impacting the lives of patients?

It turns out, I am, but maybe not how you would expect. One of the more challenging aspects of our work as CDI professionals is physician engagement, which is why connecting our work to the patient level is so important. Many providers don’t want to hear about how their documentation impacts hospital reimbursement and it difficult to demonstrate a direct impact between their documentation and quality performance measures except when a patient dies, which is a sensitive subject. That is why I’m so excited to share with you an Agency for Healthcare Research and Quality (AHRQ) call to action to improve diagnosing patients.

The importance of documenting a diagnosis in the health record extends beyond its impact on reimbursement and quality-of-care measures. It is also critical to patient safety. AHRQ states, “The diagnosis explains a patient’s health problem, informs every subsequent healthcare decision, and is developed through the iterative process of information gathering, information integration, and information interpretation.” Good patient outcomes require the right diagnosis.

According to AHRQ, diagnostic errors are an emerging safety concern that can “involve up to 12 million patients annually in U.S. ambulatory settings alone and contribute to death for up to 80,000 patients in U.S. hospitals annually.” It involves missed opportunities related to various aspects of the diagnostic process that includes “recognition of key signs, symptoms, and test results.” Diagnostic errors contribute to diagnostic safety events, which may or may not result in patient harm. These are defined by AHRQ as the following:

There were one or more missed opportunities to pursue or identify an accurate and timely diagnosis (or other explanation) of the patient’s health problems based on the information that existed at the time.

An accurate diagnosis (or other explanation) of the patient’s health problems was available, but it was not communicated to the patient (includes patient’s representative or family as applicable).”

Although there are many factors that contribute to diagnostic errors, the primary objective is to identify a patient’s illness quickly and accurately, a goal shared by CDI professionals. One of the primary contributors to diagnostic errors is the current state of diagnosis education. “Diagnosis begins with obtaining an appropriate history from the patient and performing a hypothesis-driven physical examination, but evidence suggests that even these most basic elements are often deficient. Diagnosis then depends on clinical reasoning to apply the clinician’s depth of knowledge in an effort to make sense of the patient findings in the appropriate context.

Clinical reasoning is challenging and represents the dominant issue in diagnostic error, as repeated studies have shown.” Many medical schools do not explicitly address clinical reasoning through curriculum dedicated to this topic. However, medical schools are not alone in this deficit, AHRQ found it also extends to nursing, pharmacy, and other fields.

CDI professionals can be part of the solution as organizations develop processes to reduce diagnostic errors. The work of CDI already includes reviewing health records for diagnoses that explain abnormal diagnostic indicators. Often CDI professionals are reluctant to query a provider immediately when documentation gaps are identified, instead preferring to give the provider the opportunity to interpret the results and arrive at a conclusion before querying, which could delay the query process and subsequent documentation of an associated diagnosis by days, but is that the best strategy?

I’ll freely admit that not all diagnosis will carry the same weight, but it is clear from the AHRQ research that CDI professionals should be more proactive in supporting patient safety related to diagnostic errors by bringing documentation gaps to the healthcare team sooner than later.

Perhaps this is the “What’s in it for me?” that CDI professionals needed all along to engage providers because accurately documenting diagnoses is a patient safety issue.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

The best practice is to add any retrospective query response as an addendum to the health record.

Although the goal of clinical documentation integrity (CDI) professionals is to issue queries concurrently, there is a subset of queries, often related to performance on quality-of-care measures (i.e., mortality) that are issued retrospectively. Recently, I’ve received a few inquiries by CDI professionals because providers at their organization are pushing back against retrospective queries, claiming they are improper or even fraudulent, so they will not even respond. So, what are the rules when it comes to retrospective queries? Or, better yet, are there any rules related to retrospective queries?

The irony is, at one time, all queries were retrospective because they were the domain of the coding department, which didn’t identify query opportunities until the coding process began. Yes, in an ideal world, queries would be issued and resolved concurrently, while the patient is still in-house. Concurrent queries allow the relevant diagnosis to be captured while patient care is being rendered, supporting continuity of care as well as providing the coder with a complete and accurate record to expedite the coding process. However, most processes for identifying cases that may be included in quality-of-care measures are post-discharge, if not retrospective, because many quality-of-care measures are identified by the ICD-10-CM and ICD-10-PCS codes that are included on the claim. As CDI professionals become more involved with quality-of-care measures, providers are likely to continue to see retrospective queries.

Are there rules related to retrospective queries? Unfortunately, like many things CDI, there is not one clear source with a definitive answer. Yes, retrospective queries are allowable, but is there a deadline as to how long after discharge a query can be asked? No. To find an answer, it’s best to examine guidelines associated with making changes to the medical record.

First, it is important to note that providers do have an obligation to adhere to general principles of medical record documentation. According to the Evaluation and Management Services Guide (February 2021), the following general principles apply:

• The medical record should be complete and legible
• The documentation of each patient encounter should include:
  • Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results
  • Assessment, clinical impression, or diagnosis
  • Medical plan of care
• If date and legible identity of the observer if the rationale for ordering diagnostic and other ancillary services is not documented, it should be easily inferred
• Past and present diagnoses should be accessible to the treating and/or consulting physician
• Appropriate health risk factors should be identified
• The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented
• The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by documentation in the medical record

The Medicare Program Integrity Manual states that “all services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected, or entered after rendering the service. When making review determinations, the MACs (Medicare Administrative Contractors), CERT (Comprehensive Error Rate Testing), Recovery Auditors, SMRCs (Supplemental Medical Review Contractors) and UPICs (Unified Program Integrity Contractors) shall consider all submitted entries that comply with the widely accepted Recordkeeping Principles … the MACs, CERT, Recovery Auditors, SMRC, and UPICs shall NOT consider any entries that do not comply with the principles listed in section B below (Recordkeeping Principals), even if such exclusion would lead to a claim denial. For example, they shall not consider undated or unsigned entries handwritten in the margin of a document. Instead, they shall exclude these entries from consideration.”

These Recordkeeping Principals apply to both paper and electronic health records that contain amendments, corrections, or late entries, which are the three ways a provider can compliantly alter their documentation within the health record:

• An addendum is used to provide information that was not available at the original time of entry, and should include the reason for the addition or clarification of information being added to the medical record
• A late entry is a record amendment used to add information that was omitted during the original entry, or
• A correction is used when a prior entry was made in error. A correction should not obliterate the initial entry.

Although many organizations allow providers to respond directly to a query, depending on the timing of the query (e.g., if it is concurrent or retrospective), a best practice would be to add any retrospective query response as an addendum to the health record, to comply with Recordkeeping Principals. As long as the response to the retrospective query is correctly added to the health record, it is not falsified documentation. According to Noridian Healthcare Solutions, a MAC for the Centers for Medicare & Medicaid Services (CMS), examples of what can be considered falsifying a health record include the following:

• Creation of a new record when a record is completed;
• Back-dating entries;
• Post-dating entries;
• Pre-dating entries;
• Writing over; and
• Adding existing documentation (except as described in late entries, addendums, and corrections).

Noridian does not reference an acceptable timeframe when record amendments can or cannot occur, but they do state that “corrections to the medical record legally amended before claims submission and/or medical review will be considered in determining the validity of services billed. If these changes appear in the record following payment determination based on medical review, only the original record will be reviewed in determining payment of services billed to Medicare.” Suggesting that queries to add documentation to refute a denial from a MAC is likely futile.

Perhaps the best guidance regarding how a CMS contractor should process clinical information derived from a query comes from Risk Adjustment Data Validation (RADV) contractors, which support audits related to the Medicare Advantage (MA) program. Their contractor reviewer guidelines include a section on query forms. Included in the guidance is a simple but accurate description of a query: “a tool used to clarify documentation in the health record for accurate code assignment.” The guidance also builds upon the definition of a query within the glossary, with a very thoughtful description: “the desired outcome from a query is an update (an “update” can be a late entry, addendum, or approved query form, per individual facility medical record documentation policy) of a health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment.”

This addition, how the record update should occur (e.g., in the form of an addendum), should be an important component of any organization’s query process. If the provider is not required to amend the discharge summary to support a retrospective query, then the query form should be designed to act as an addendum to the health record and meet all the Recordkeeping Principals.

RADV guidance related to the acceptance of query forms is as follows: “when submitted with the associated medical record, diagnosis query forms that are completed, signed, and dated promptly (i.e., within 90 days of the date of service) by the physician/practitioner and became part of the official medical record will be reviewed for validity and clinical consistency with the medical record documentation.”

This guidance contrasts with what was issued in 2004, as referenced in the article, “Querying Physicians to Improve Documentation and Dx Coding” (Barton, D. 2017), which references that “the correction should be within 30 days of the initial documentation, and substantial reasoning must be provided for the change.” Most organizations will likely remain within a 30-day time frame when it comes to retrospective queries due to the potential impact on facility metrics like days of bill hold, and the potential issues associated with rebilling a claim, so maybe this discrepancy is not an issue for most organizations.

What is particularly interesting regarding the RADV guidance is that it also clearly states whose documentation can and cannot be used to amend the health record, stating, “only the attending or treating physician can amend the medical record … it is not appropriate to add diagnoses to the medical record that have been identified by a source other than the treating physician (e.g., identifying diabetes from a disease management program).”

Although this seems like a reasonable requirement, I have heard discussions regarding the use of non-treating providers to amend health records as a way to “expedite” the query process. As more CDI departments have Physician Advisors who see patients, it is important to clearly outline when the Physician Advisor may document in a health record. A best practice would be to include a policy that only allows a member of the medical staff to document a patient’s health record when they are part of the treating medical team.

The RADV guidance also elaborates upon who can perform queries:

“Query type forms generated by the MA organization, or their coding staff contractors, are not acceptable for review as part of the medical record. They are considered extraneous data from an alternative data source not allowed, per risk-adjustment policy.”

“Query forms will be considered on a case-by-case basis to determine whether the document is an acceptable standard physician query made by a coder or similar facility staff at or near the time of the encounter, or if it is some other unacceptable late addition of conditions after the original encounter.”

“RADV reviewer will not code from documents even if labeled (incorrectly) as ‘coder query’ if the documentation is not generated at or near the time of the encounter by the facility or physician office.”

The query process is the responsibility of the organization’s CDI or coding staff, and responding to a query is the responsibility of a treating provider. Querying is a complex process, and it involves coordination between CDI and coding professionals with the treating medical team, as well as other members of the health information management team who manage and release the health record. Often, multiple sources of information must be cobbled together to create a compliant process. When it comes to a compliant query process, it is not only important to understand the rules pertaining to that process, but also the rules for amending the health record. Embracing these rules can grow physician support for retrospective queries by helping them understand that record amendments are an ethical and compliant process, accepted by CMS.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

HACRP is designed to reduce rates of healthcare-associated infections

Most clinical documentation improvement (CDI) professionals are aware of hospital-acquired conditions (HACs). In fact, reviewing a record and looking for potential HACs may be part of their standard workflow. What many who perform these reviews or manage the CDI process may not realize is that the concept of HACs, and along with it a focus on patient safety, was expanded with the Hospital-Acquired Conditions Reduction Program (HACRP). Yes, HACs are still around, but their potential financial impact at an individual healthcare organizational level is far less than a penalty incurred under the HACRP.

HACs were one of the Centers for Medicare & Medicaid Services’ (CMS’s) first ventures into aligning payment and quality of care. They were developed as part of the Deficit Reduction Act (DRA) of 2005, which required the Secretary of the U.S. Department of Health and Human Services (HHS) (which oversees CMS) to “identify conditions that are: a) high-cost, high-volume, or both; b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis; and c) could reasonably have been prevented through the application of evidence-based guidelines.” However, HACs were not implemented until the Inpatient Prospective Payment System (IPPS) Final Rule for the 2009 fiscal year (FY). Part of the reason for this delay was that implementation of HACs was dependent upon implementation of the present-on-admission indicator (POA). Prior to implementation of the POA indicator, CMS did not have an objective way of differentiating co-morbidities (e.g., those conditions that existed prior to the admission) from complications (those conditions that arose during the admission). In this context, complications do not imply wrongdoing on the part of the healthcare organization; it is merely the terminology CMS used.

There were initially 10 categories of HACs, but it subsequently grew to 14 categories, and has remained at 14 since the IPPS for FY 2013 was introduced. Basically, few changes have occurred with HACs, except for the conversion to the ICD-10-CM/PCS code set (which occurred in FY 2016), since the FY 2013 update. The current categories of HACs are:

• Foreign Object Retained After Surgery
• Air Embolism
• Blood Incompatibility
• Stage III and IV Pressure Ulcers
• Falls and Trauma (e.g., Fractures, Dislocations, Intracranial Injuries, Crushing Injuries, Burn, Other Injuries)
• Manifestations of Poor Glycemic Control (e.g., Diabetic Ketoacidosis, Nonketotic Hyperosmolar Coma, Hypoglycemic Coma, Secondary Diabetes with Ketoacidosis, Secondary Diabetes with Hyperosmolarity)
• Catheter-Associated Urinary Tract Infection (UTI)
• Vascular Catheter-Associated Infection
• Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG):
• Surgical Site Infection Following Bariatric Surgery for Obesity
  • Laparoscopic Gastric Bypass
  • Gastroenterostomy
  • Laparoscopic Gastric Restrictive Surgery
• Surgical Site Infection Following Certain Orthopedic Procedures
  • Spine
  • Neck
  • Shoulder
  • Elbow
• Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)
• Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic Procedures:
  • Total Knee Replacement
  • Hip Replacement
• Iatrogenic Pneumothorax with Venous Catheterization

You can find a listing of HACs for FY 2022 and the associated ICD-10-CM/PCS codes online at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.

So, what is the possible impact of HACs, and why do some CDI departments include identification of potential HACs in their review process? According to a 2020 FAQ published by CMS, “hospitals no longer receive additional payment for cases in which one of the identified HACs occurred but was not POA. Instead, the case is paid as though the HAC was not present. This payment provision applies only to secondary diagnosis codes, given that the identified HACs are designated as a complication or comorbidity (CC) or a major complication or comorbidity (MCC) when reported as a secondary diagnosis. Payments will be adjusted only if no other CC/MCC conditions are reported on the claim.” In other words, if a HAC is identified on the claim, that condition can no longer impact the MS-DRG assignment as a CC or MCC, which could negatively impact reimbursement for that particular claim if there is not another CC or MCC to replace the impact of the HAC. The impact is limited to one claim, and only if it was the only secondary diagnosis that impacted the MS-DRG assignment.

Due to efforts by CDI departments to have multiple CCs and MCCs on every claim, when possible, HACs have little if any financial impact on most healthcare organizations. CMS does, however, publicly report HACs for Foreign Object Retained After Surgery; Blood Incompatibility; Air Embolism; and Falls and Trauma because these measures are not covered by any other CMS quality program. However, CMS does not risk-adjust HAC measures based on patient case mix, because these are considered by CMS “to be serious, reportable events that should not occur, regardless of the patient’s condition.” All other HACs have been “absorbed” into other CMS quality measures, such as CMS PSI 90, which is included in the HACRP. Although they both include the concept of hospital-acquired conditions, the HAC (POA) program and HACRP are two distinctly different quality programs.

According to CMS, “the Hospital-Acquired Condition (HAC) Reduction Program is a Medicare value-based purchasing program that reduces payments to hospitals based on how they perform on measures of hospital-acquired conditions.” It was established by the Patient Protection and Affordable Care Act of 2010 and implemented with the IPPS for FY 2015. The HACRP is designed to encourage use of best practices by healthcare organizations to reduce rates of healthcare-associated infections (HAIs) and improve patient safety. Unlike the HAC program, which only impacts CMS reimbursement on a per-claim basis, the HACRP “adjusts payments to hospitals that rank in the worst-performing quartile (above the 75th percentile) … with respect to measures of hospital-acquired conditions. On an annual basis, CMS evaluates overall hospital performance by calculating a Total HAC Score for each hospital as the equally weighted average of their scores on measures included in the program. Hospitals with a Total HAC Score greater than the 75th percentile of all Total HAC Scores … receive a payment reduction of 1 percent on overall Medicare fee-for-service (FFS) payments.”

Additionally, data collected for the HACRP is publicly reported. The HACRP is updated annually as part of the IPPS. Currently, The HAC Reduction Program includes the following six quality measures:

• One claims-based composite measure of patient safety:
  • CMS Patient Safety and Adverse Events Composite (CMS PSI 90)
• Five chart-abstracted measures of HAIs submitted to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network:
  • Central Line-Associated Bloodstream Infection (CLABSI)
  • Catheter-Associated Urinary Tract Infection (CAUTI)
  • Surgical Site Infection (SSI) for abdominal hysterectomy and colon procedures
  • Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
  • Clostridium difficile Infection (CDI)

It is important to note that data related to HAIs is not based on claims data; this data is routinely collected as surveillance data by infection control teams and submitted directly to the CDC. Another key difference between the HAC program and HACRP is that the HAC program occurs in real time. The penalty is assessed when the claim is submitted because it is built into claims payment logic. Conversely, data used to determine payment penalties for the HACRP is collected several years prior to the application of the penalty. The FY 2022 HACRP performance period for CMS PSI 90 is based on data collected from July 1, 2018 to Dec. 31, 2019, and the data for the HIA measures was collected from the 2019 calendar year (CY). If organizations only improve patient safety once they receive a HACRP penalty, it could take several years before they are able to right the ship to avoid additional penalties. The good news about HACRP from the CDI perspective is that monitoring performance aligns with efforts to monitor patient safety indicators (PSIs) due to the composite measure of CMS PSI 90, so many CDI departments already have processes in place that could be expanded to include the HACRP.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

“Upcoding” remains a common mechanism of improper payments.

“Healthcare compliance is the process of following rules, regulations and laws that relate to healthcare practices,” according to the PowerDMS Policy Learning Center. Although all healthcare organizations have a compliance department, how the clinical documentation integrity (CDI) department interacts with compliance and supports practices compliant with Centers for Medicare & Medicaid Services (CMS) regulations varies across health systems. The purpose of a compliance program is to prevent, detect, and correct non-compliance to avoid fraud, waste, and abuse.

According to the U.S. Department of Health and Human Services (HHS), some healthcare entities pose a heightened risk to the financial security of Medicare due to the volume of improper payments they incur. Healthcare organizations have a duty to submit proper claims to CMS; however, “upcoding” remains a common mechanism of improper payments. Because compliance is the responsibility of everyone employed by the health system, CDI leadership should be actively engaged in monitoring CMS claims data for potential overpayments that could represent simple errors or process issues resulting in institutional non-compliance. In particular, CDI departments should be gatekeepers meant to avoid “billing for services at a level or complexity higher than services actually provided or documented in the medical record,” according to CMS.

An overpayment is defined by Medicare as one that “exceeds regulation and statute properly payable amounts.” Medicare overpayments can occur due to “incorrect coding and/or insufficient documentation,” both of which should be monitored by CDI and coding leadership. Healthcare entities have 60 days from overpayment identification to report and return a self-identified overpayment to Medicare. Reporting of an overpayment should include a written explanation for the overpayment, e.g., coding error, failure to follow organizational billing practices, etc. The concept of “identification” is broadly applied, as the rule states that this means when a person has or “should have, through the exercise of reasonable diligence” determined an overpayment.

Misusing codes on a claim, such as upcoding (when a provider assigns an inaccurate billing code to a medical procedure or treatment to increase reimbursement) and coding errors are examples of Medicare abuse if the incorrect coding or billing practices are not widespread practices, in which case it could be an example of fraud. CDI and coding professionals are both subject to the federal civil False Claims Act (FCA):

“The civil FCA imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the Federal Government. The terms ‘knowing’ and ‘knowingly’ mean a person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information related to the claim. No specific intent to defraud is required to violate the civil FCA.”

CMS has a variety of tools to monitor inaccurate payments, including the Comprehensive Error Rate Testing (CERT) Program, Medicare Administrative Contractors (MACs), and the Recovery Auditors. According to CMS, the CERT program reviews a statistically valid stratified random sample of Medicare fee-for-service (FFS) claims to determine if they were paid properly under Medicare coverage, coding, and payment rules. CERT findings create the framework for MAC audits and those performed by Recovery Auditors. While CERT leverages a random sample of claims, the Program for Evaluating Payment Patterns Electronic Report (PEPPER) data provides hospital-specific Medicare claims data. Target areas included in PEPPER were identified by Recovery Auditors and MACs, and are updated periodically.

“PEPPER is an electronic report that provides provider-specific Medicare data statistics for discharges/services vulnerable to improper payments. PEPPER cannot be used to identify the presence of payment errors, but it can be used as a guide for auditing and monitoring efforts to help providers identify and prevent payment errors.”

If you manage a CDI or coding department, you should be reviewing your PEPPER data on a quarterly basis; however, the national download rate is currently at 62 percent. Failure to monitor Medicare claims data included in PEPPER can be an example of “deliberate ignorance or reckless disregard,” according to ACDIS, if your organization is an outlier. Although PEPPER data is not specifically distributed to Recovery Auditors or MACs, both of these Medicare contractors have the ability to request charts related to PEPPER target areas, and have sophisticated data mining techniques to identify outliers.

PEPPER target areas are constructed as a ratio. The numerator includes discharges identified from paid Medicare claims per CMS fiscal year (i.e., October to September) quarter that are identified as potentially problematic because they are likely to be miscoded or result in medically unnecessary services. The denominator is the larger reference group that includes the numerator.

For this article, our focus is coding target areas that include:

• Stroke Intracranial Hemorrhage;
• Respiratory Infections;
• Simple Pneumonia;
• Septicemia;
• Unrelated OR Procedures;
• Medical DRGs with CC or MCC;
• Surgical DRGs with CC or MCC;
• Single CC or MCC;
• Severe Malnutrition;
• Excisional Debridement;
• Ventilator Support; and
• Emergency Department Evaluation and Management Visits.

Each hospital’s ratio is compared to other hospitals at the state, MAC jurisdiction, and national levels, resulting in a ranking by volume percentage. PEPPER data uses the high outlier threshold of the 80th percentile and a low outlier threshold of the 20th percentile. If the percentage of paid Medicare claims for the specific target area ranks at the 80th percentile or above, the organization is considered a high outlier for that target area. In other words, the percentage range for a particular target area may be from 20 to 75 percent. The 80th percentile may result in all those hospitals with a target area ratio of 68 percent or higher. The ratios among all hospitals and the 80th percentile cutoff will vary from quarter to quarter.

If you are new to PEPPER and integrating a compliance focus into your CDI or coding practices, a good place to start is the National High Outlier Ranking Report. This page of PEPPER data will have red if your organization is a high outlier in any target area across the most recently reported 12 quarters of data, as well as the total number of times your organization was a high outlier for each target area. If your organization happens to be a high outlier for any coding target area, that does not necessarily mean there is a compliance issue. A best practice is to investigate why your organization is an outlier by sampling claims and reviewing documentation to validate the assigned codes and billing. Ask yourself, does it make sense for your hospital to be among the top 20 percent of all hospitals for that particular target area?

CDI departments are increasingly renaming the “I” from “improvement” to “integrity.” Integrity is defined as “the quality of being honest and having strong moral principles.” Reviewing PEPPER data is a way for CDI and coding managers to identify areas that may be vulnerable to overpayment. If outliers exist, investigate the associated claims to validate the coding and billing. If coding or billing errors occurred, determine the cause(s) of the errors, e.g., human error or process issues, and look for ways to prevent future non-compliant coding and billing practices. Even if your organization is not an outlier or the internal investigation does not reveal the potential for overpayment, CDI and coding leadership should ensure there are safeguards in place to prevent non-compliance, and monitor staff adherence to those processes.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

Do health information management (HIM) and clinical documentation integrity (CDI) professionals need a standard operational definition for “clinical documentation?” Put another way, should everything within a physician note, for example, be considered clinical documentation?

Back in the day of paper records, it was easy to distinguish between a template header, a prompt, and physician documentation, because the template was preprinted and the physician documentation was handwritten or transcribed. With movement towards the electronic medical record (EMR), it is more difficult to differentiate what the provider entered into the record from what is part of a template, from what was “pulled forward” by the provider, from what was auto-populated by the EMR, etc.

Why does this matter? Well, I review a lot of records in my role, and I am seeing a lot of cases in which words or phrases within the health record are being used to report an associated diagnosis; however, Official Coding Guidelines for reporting “other diagnoses” are not met. Specifically, the Coding Guidelines state:

For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:

• Clinical evaluation;
• Therapeutic treatment;
• Diagnostic procedures;
• Extended length of hospital stay; or
• Increased nursing care and/or monitoring.

The UHDDS (Uniform Hospital Discharge Data Set) item No. 11-b defines other diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.” UHDDS definitions apply to inpatients in acute care, short-term care, long-term care, and psychiatric hospital settings.

Not only is technology changing how the medical record is formatted, but it is also changing how CDI and coding professionals perform their duties. A 2015 article published by the American Health Information Management Association (AHIMA, Weinberg, J, et. al) defined computer-assisted coding (CAC) as the use of computer software that automatically generates a set of medical codes for review and validation, based upon the clinical documentation of healthcare practitioners. Furthermore, “CAC includes a variety of computer-based approaches that do not require human interaction to transform narrative text in clinical records into structured text, which may include assignment of codes from standard terminologies such as ICD-9-CM, ICD-10-CM/PCS, CPT/HCPCS, and SNOMED CT.”. However, the article also warns,

“CAC requires a very high level of data integrity. This is due to the inherent nature of natural language processing (NLP) engines. These engines utilize a lexicon to determine if documentation meets criteria to be assigned a final code. If the CAC engine cannot understand a term, concepts are not completely documented, or terms are spelled incorrectly, then the engine may not recognize the term and assign a code accordingly.”

As someone who works in the technology field, I must say that my personal experience is that few CAC tools are robust enough to actually consider the context of the documentation to see if it meets criteria for code assignment. Yes, CAC tools can identify when a term like “shock” appears, for example, and map it to the associated unspecified code for shock, but not all of them are able to realize that the word was highlighted as part of the phrase “shock index,” which is a header within the template to support clinical assessment. In other words, in this context “shock” isn’t even a documented diagnosis. It is simply a header within the health record prompting the provider to complete a comprehensive patient assessment. Depending on the sophistication of the NLP engine, some are able to determine the context of a word as a positive or a negative mention. For example, “no heart failure” would be a negative mention, but what about when the assessment of heart failure is part of a template, so it appears as “heart failure: negative” or “heart failure: absent,” or any other number of variations? Not all NLP engines are able to process terms like a historical mention of a condition, or when it references a family member (or when it is uncertain).

There are also many EMRs that can import ICD-10-CM Codes or SNOMED CT codes with an associated code title as the physician enters data. In some records, the only reference to a particular diagnosis may be the code title. Is this really clinical documentation? I know there has been and continues to be much debate about problem lists, but what about code titles? Keep in mind that the Official Coding Guidelines state, “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists.” A code title is not the same as a diagnostic statement, and it doesn’t support the condition as reportable.

Another situation to consider is related to the ability to copy notes within the EMR. I have reviewed many records in which documentation from the history and physical (H&P) is copied forward into the discharge summary. Although this may be a time-saver for the provider, it is problematic when the H&P states that a patient is admitted for “possible pneumonia” or “suspected sepsis” – or any other condition that is, understandably, uncertain at the time of admission. However, when this documentation is copied into the discharge summary, many coders erroneously invoke the Official Coding Guidelines regarding the reporting of uncertain diagnoses:

If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The basis for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

Yes, the discharge summary contains the words “possible pneumonia;” however, the totality of the record usually demonstrates that the pneumonia (or other possible conditions) was ruled out. Again, the diagnosis likely does not meet reporting guidelines. I find that these cases are particularly prevalent within the newborn population, as many within this patient population are admitted for a suspected condition or in order to rule out a condition.

So, let’s get back to basics, and make sure our CDI and coding teams are taking the time to validate terms within the health record to confirm them as clinical documentation that reflects a “diagnostic statement.” Let’s also reinforce the need to meet Official Coding Guidelines for reporting “other diagnoses.”

Not all words that can be mapped within a health record to a diagnosis code are clinical documentation or reportable.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

As a former manager of clinical documentation integrity (CDI) and utilization review (UR) at an academic medical center, my focus was on understanding all possible sources of revenue leakage. At that time, the UR staff focused on activities that demonstrated a patient’s medical necessity, as defined by a variety of payers, but often required application of InterQual criteria, while the CDI team focused on capturing patient acuity to support accurate reimbursement under the Inpatient Prospective Payment System (IPPS) and other DRG payers.

However, we had a blind spot – before medical necessity can be supported and diagnoses reported on a claim, the services provided must first be covered by the payer. The approval process is somewhat straightforward, when it comes to commercial payers, as it involves prior authorizations (or precertification) – and most healthcare organizations have staff dedicated to obtaining these authorizations. But this is less well-known when it comes to Medicare beneficiaries.

Medicare coverage polices specify which items and services are covered under the Medicare program, and under which circumstances – such as when required specific clinical criteria are met. We see some outpatient CDI efforts supporting medical necessity (e.g., ensuring that the right diagnosis codes are included with imaging or injections), but it is far less common in the inpatient setting, where healthcare is much more expensive. When specific clinical criteria must be met to support Medicare coverage, it is often outlined in National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). The Centers for Medicare & Medicaid Services (CMS) states that “services must meet specific medical necessity requirements in the statute, regulations, manuals, and specific medical necessity criteria defined by National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), if any apply to the reported service. For every service you bill, you must indicate the specific sign, symptom, or patient complaint that makes the service reasonable and necessary.”

Now, not all services have NCDs or LCDs, but if there is one associated with a service, the medical necessity must be demonstrated with specific clinical criteria. Some services are specialized (e.g., transcatheter aortic valve replacement, or TAVR), and there may be a dedicated team within your organization to serve these types of patients – and they may be responsible for demonstrating the service as covered, while other, less specialized procedures (e.g., implantable cardioverter defibrillators (ICDs) or cardiac pacemakers) may also have associated NCDs. The NCD for ICDs has only been effective since 2018, but the NCD for single-chamber cardiac pacemakers has been effective since 1983.

An example of criteria that must be included for a single-chamber cardiac pacemaker to be covered are the following diagnoses, which must be “chronic or recurrent and not due to transient causes such as acute myocardial infarction, drug toxicity, or electrolyte imbalance:”

• Acquired complete (also referred to as third-degree) AV heart block;
• Congenital complete heart block with severe bradycardia (in relation to age), or significant physiological deficits or significant symptoms due to the bradycardia;
• Second-degree AV heart block of Type II (i.e., no progressive prolongation of P-R interval prior to each blocked beat. P-R interval indicates the time taken for an impulse to travel from the atria to the ventricles on an electrocardiogram);
• Second-degree AV heart block of Type I (i.e., progressive prolongation of P-R interval prior to each blocked beat) with significant symptoms due to hemodynamic instability associated with the heart block; and
• Sinus bradycardia associated with major symptoms (e.g., syncope, seizures, congestive heart failure), or substantial sinus bradycardia (heart rate less than 50) associated with dizziness or confusion. The correlation between symptoms and bradycardia must be documented, or the symptoms must be clearly attributable to the bradycardia, rather than to some other cause.

NCDs are established criteria for when a service is not covered by Medicare, for example regarding the single-chamber pacemaker: “conditions which, although used by some physicians as a basis for permanent cardiac pacing, are considered unsupported by adequate evidence of benefit and therefore should not generally be considered appropriate uses for single-chamber pacemakers in the absence of the above indications.” These include:

1. Syncope of undetermined cause;
2. Sinus bradycardia without significant symptoms;
3. Sino-atrial block or sinus arrest without significant symptoms;
4. Prolonged P-R intervals with atrial fibrillation (without third-degree AV block) or with other causes of transient ventricular pause;
5. Bradycardia during sleep;
6. Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent AV block);
7. Asymptomatic second-degree AV block of Type I, unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His bundle (a component of the electrical conduction system of the heart); and
8. Asymptomatic bradycardia in post-MI patients about to initiate long-term beta-blocker drug therapy (effective Oct. 1, 2001).

LCDs are similar to NCDs, but defined by the Social Security Act as a “a determination by a fiscal intermediary or a carrier under Part A or Part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis.” General information about LCDs can be found in Chapter 13 of the Medicare Program Integrity Manual. However, specific LCDs would be available from the applicable Medicare Administrative Contractor (MAC), or there is a searchable database for both NCDs and LCDs at https://www.cms.gov/medicare-coverage-database/new-search/search.aspx. An example of an LCD is cardiac catheterization and coronary angiography, which is currently effective for two contractors. This LCD outlines indications supporting a right, left, or both a right and left heart catheterization, as well as limitations (such as when a right heart catherization or left heart catheterization is not considered medically necessary).

As you can see from the NCD example above, these criteria don’t really fall into typical CDI or UM work, but could result in significant lost revenue if not provided when necessary. There is a component of both departments, as there is often a requirement for specific diagnoses to be present, often with an associated ICD-10-CM code (of note, CMS is still in the process of converting ICD-9-CM codes to ICD-10-CM/PCS codes for some NCDs and LCDs), as well as supporting clinical criteria so the diagnosis can be clinically validated. To see an example of what updated codes are included in the NCD for ICDs, effective July 6, 2021, go online to www.cms.gov/files/document/r10635CP.pdf. This document provides instructions to the MACs when processing claims for ICDs to ensure that NCD criteria are met by listing what ICD-10-CM and ICD-10-PCS codes should be present on the claim.

As CDI departments continue to grow, some are venturing out into to new areas like covered services, as defined by NCDs and LCDs, to avoid service denials. Unlike DRG changes, these types of denials often result in no payment, rather than reduced payment, which can be costly if it involves a procedure and the cost cannot be shifted to the Medicare beneficiary if due diligence was not completed by the organization. This is not an area that can be easily integrated in the CDI workflow, so it would likely require dedicated CDI staff with knowledge and understanding of where to find NCDs/LCDs and how to apply the criteria correctly.

By: Timothy Brundage, MD, CCDS, Medical Director & CEO of Brundage Group

The diagnosis of Healthcare-Associated Pneumonia (HCAP) is clinically out of date and does not effectively code. The diagnosis of HCAP maps to the DRG for simple pneumonia. Simple pneumonia is a diagnosis that can often be treated in the outpatient setting. HCAP clearly does not fit into this DRG grouping, so physicians should update their clinical practice and their documentation.

Here’s why physicians should not document Healthcare-Associated Pneumonia:

• The diagnosis of HCAP is clinically out of date.
• HCAP does not code effectively.
• The use of HCAP as a diagnosis is discouraged by the Infectious Diseases Society of America.
• HCAP is the wrong diagnosis!

Oral antibiotics are extremely effective in treating simple pneumonia. If a patient truly demonstrates medical necessity for inpatient admission to the hospital, the patient likely has either complex pneumonia or sepsis. (Severe) sepsis is now defined as organ dysfunction due to the infectious process, however, physicians often fail to link the pneumonia with the organ dysfunction. Physicians should update their documentation practices.

As an example: a patient is admitted to the hospital with the diagnoses of pneumonia and acute kidney injury (AKI). Effective documentation would link the conditions as “pneumonia causing AKI.” When pneumonia causes the AKI, then the physician should properly diagnose the patient with sepsis or severe sepsis, explicitly linking the organ dysfunction to the infection.

It is exceedingly common for physicians to admit patients to the hospital and treat them with very aggressive antibiotics without adequately documenting a diagnosis to support the reason why “big-gun” antibiotics are necessary. Physicians should allow their choice of antibiotics to drive their documentation.

For example, the following language is clinically appropriate and codes effectively.

• Zosyn, to treat suspected gram negative (pseudomonas) pneumonia
• Vancomycin, to treat suspected MRSA pneumonia
• Zosyn, Clindamycin or Flagyl, to treat suspected aspiration pneumonia

If hospitalists are scrutinized by length of stay metrics, they should understand that expected length of stay (LOS) is calculated using the documented diagnoses. Suspected gram-negative pneumonia creates a longer expected LOS in the hospital than does simple pneumonia.

Our physician-to-physician education creates savvy documenters who understand how to use coding-based language to demonstrate medical necessity and accurately calculate the DRG. With our support, physicians can learn to document effectively to capture the patient’s severity of illness to support the DRG and quality metrics.

Learn more about our services.

The SCCM and ESICM have published “Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-associated Organ Dysfunction in Children” to provide guidance for clinicians caring for children with septic shock and other sepsis-associated organ dysfunction (not sepsis without shock/organ dysfunction). New included guidelines are not intended to update or iterate on prior recommendations for the care of children with sepsis and septic shock (not sepsis without shock/organ dysfunction).

Although application of Sepsis-3 to children has been attempted (19,20), formal revisions to the 2005 pediatric sepsis definitions remain pending (21). Therefore, the majority of studies used to establish evidence for these guidelines referred to the 2005 nomenclature in which severe sepsis was defined as 1) greater than or equal to two age-based systemic inflammatory response syndrome (SIRS) criteria, 2) confirmed or suspected invasive infection, and 3) cardiovascular dysfunction, acute respiratory distress syndrome (ARDS) or greater than or equal to two non-cardiovascular organ system dysfunctions; and septic shock was defined as the subset with cardiovascular dysfunction, which included hypotension, treatment with a vasoactive medication or impaired perfusion.

The article defines septic shock in children as severe infection leading to cardiovascular dysfunction (including hypotension, need for treatment with a vasoactive medication or impaired perfusion) and “sepsis-associated organ dysfunction” in children as severe infection leading to cardiovascular and/or non-cardiovascular organ dysfunction. Because several methods to identify acute organ dysfunction in children are currently available (17,19,20,22,23), the authors chose not to require a specific definition or scheme for this purpose.

This report covers five main topic areas:

• early recognition
• infection therapies and adjunctive therapies
• hemodynamics therapies and adjunctive therapies
• ventilation therapies and adjunctive therapies
• endocrine therapies adjunctive therapies
• metabolic therapies and adjunctive therapies

Some notable aspects/differences of this report:

• The article did not issue a recommendation about using blood lactate values to stratify children with suspected septic shock or other sepsis-associated organ dysfunction into low- versus high-risk of having septic shock or sepsis. However, in practice, if lactate levels can be rapidly obtained, measure blood lactate in children when evaluating for septic shock and other sepsis-associated organ dysfunction may have merit. Unfortunately, the optimal threshold to define “hyperlactatemia” in children remains unclear.
• The article suggests using balanced/buffered crystalloids, rather than 0.9% saline, for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction (weak recommendation, very low quality of evidence).
• Recommendations do not apply to premies < 37 weeks or infants < 28 days of age.

17. Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis: International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6:2–8

19. Matics TJ, Sanchez-Pinto LN. Adaptation and validation of a pediatric sequential organ failure assessment score and evaluation of the sepsis-3 definitions in critically ill children. JAMA Pediatr 2017; 171:e172352

20. Schlapbach LJ, Straney L, Bellomo R, et al. Prognostic accuracy of age-adapted SOFA, SIRS, PELOD-2, and qSOFA for in-hospital mortality among children with suspected infection admitted to the intensive care unit. Intensive Care Med 2018; 44:179–188

21. Schlapbach LJ, Kissoon N. Defining pediatric sepsis. JAMA Pediatr 2018; 172:312–314

22. Leteurtre S, Duhamel A, Salleron J, et al.; Groupe Francophone de Réanimation et d’Urgences Pédiatriques (GFRUP): PELOD-2: An update of the PEdiatric logistic organ dysfunction score. Crit Care Med 2013; 41:1761–1773

23. Proulx F, Gauthier M, Nadeau D, et al. Timing and predictors of death in pediatric patients with multiple organ system failure. Crit Care Med 1994; 22:1025–1031

The health care industry continues to transition toward a value-based, pay-for-performance system, but there’s still confusion surrounding the different quality and value programs that have been introduced by CMS and how they impact hospitals.

There’s good reason for the confusion. The programs themselves share terminology, leaving you asking yourself, “How does the HAC Deficit Reduction Act differ from the HAC Reduction Program?” Further, quality measures, such as catheter-associated urinary tract infection (CAUTI), span all three programs, yet are calculated differently depending on the program.

It’s critically important for stakeholders to understand the components of each program, as well as how the programs are measured, to implement appropriate action plans to improve quality and prevent CMS penalties. We travel the country clearing up the confusion for hospital organizations, and we’re breaking it down for you here.

This program includes the traditional hospital-acquired conditions (HAC). All of these conditions qualify as either a complication/comorbidity (CC) or a major complication/comorbidity (MCC). However, if the condition develops after admission, it will be excluded from counting as a CC or MCC for reimbursement purposes. In addition, the first four conditions on the list are publicly reported on the Hospital Compare website.

• Foreign object retained after surgery **
• Air embolism **
• Blood incompatibility **
• Falls and trauma **
  • Fractures
  • Dislocations
  • Intracranial injuries
  • Crushing injuries
  • Burn
  • Other injuries
• Stage III and IV pressure ulcers
  • Manifestations of poor glycemic control
  • Diabetic ketoacidosis
  • Nonketotic hyperosmolar coma
  • Hypoglycemic coma
  • Secondary diabetes with ketoacidosis
  • Secondary diabetes with hyperosmolarity
• CAUTI
• Vascular catheter-associated infection
• Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG)
• Surgical site infection following bariatric surgery for obesity
  • Laparoscopic gastric bypass
  • Gastroenterostomy
  • Laparoscopic gastric restrictive surgery
• Surgical site infection following certain orthopedic procedures
  • Spine
  • Neck
  • Shoulder
  • Elbow
• Surgical site infection following cardiac implantable electronic device (CIED)
• Deep vein thrombosis (DVG) / Pulmonary embolism (PE) Following certain orthopedic procedures
  • Total knee replacement
  • Hip replacement
• Iatrogenic pneumothorax with venous catherization

**Publicly reported on Hospital Compare

It’s a startling fact: Under the HAC Reduction Program, hospitals performing in the bottom 25% receive a 1% penalty. The penalty is applied across all Medicare hospitalizations for the year. For a large hospital, the penalty can be over $1 million per year.

The HAC Reduction Program is comprised of patient safety indicator (PSI) 90 (The Patient Safety and Adverse Events Composite), as well as healthcare-associated infections (HAI). PSI 90 was developed by the Agency for Healthcare Research and Quality (AHRQ) and is used to track potential complications and adverse events. Each PSI has unique criteria based on the coded diagnoses in the medical record. Accurate clinical documentation is critical to ensure appropriate clinical care is not inadvertently captured as a complication. PSI 90 is a composite of the following 10 PSIs:

1. PSI 03 Pressure Ulcers
2. PSI 06 Iatrogenic Pneumothorax
3. PSI 08 In Hospital Fall with Hip Fracture
4. PSI 09 Perioperative Hemorrhage or Hematoma
5. PSI 10 Post-op Acute Kidney Injury Requiring Dialysis
6. PSI 11 Post-op Respiratory Failure
7. PSI 12 Peri-op Pulmonary Embolism or Deep Vein Thrombosis
8. PSI 13 Postoperative Sepsis
9. PSI 14 Postoperative Wound Dehiscence
10. PSI 15 Unrecognized Abdominopelvic Accidental Puncture/Laceration

In contrast to PSIs, HAIs are less dependent on clinical documentation and are instead based on abstraction rules developed by the CDC. The following HAIs are abstracted from the hospital chart and reported to the National Healthcare Safety Network (NHSN):

• Central line-associated bloodstream infection (CLABSI)
• Catheter-associated urinary tract infection (CAUTI)
• Surgical site infection (SSI) (colon and hysterectomy)
• Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
• Clostridium difficile infection

Performance measures under this program give hospitals the potential for up to a 2% penalty or even a bonus, based on the performance of the various measures. There are four domains that are equally weighted: clinical care, person and community engagement, safety, and efficiency and cost reduction.

The same five HAIs reported in the HAC Reduction Program are also included in the Hospital Value-Based Purchasing Program.

• CLABSI
• CAUTI
• SSI (colon and hysterectomy)
• MRSA bacteremia
• Clostridium difficile infection

In addition, PC-01, elective delivery prior to 39 completed weeks gestation, is included for hospitals that offer obstetrics.

This domain is assessed based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).Also known as the CAHPS Hospital Survey, it measures patients’ perceptions of their hospital experiences.

This domain is based on Medicare spending per beneficiary. It is risk adjusted and the spending per beneficiary is compared to all hospitals across the nation. The goal of this measure is to reward hospitals that provide comparable care at a lower cost.

The clinical care domain includes six mortality metrics that are publicly reported:

• Acute myocardial infarction (AMI)
• Heart failure (HF)
• Pneumonia
• Chronic obstructive pulmonary disease (COPD)
• Stroke
• CABG

While all six of these mortality metrics are publicly reported, only AMI, HF, and pneumonia are included in the financial calculation of the Hospital Value-Based Purchasing Program.

Medicare’s mortality metric has significant financial and reputation implications. It is important to understand that conditions that develop after admission are not included in the risk adjustment, whereas conditions that are present on admission (POA) are included in risk adjustment. Herein lies the importance of capturing diagnoses as POA when clinically appropriate.

If it’s unclear whether the condition is POA, a query may be warranted to ensure that all diagnoses that contribute to risk adjustment are captured. Additionally, diagnoses that are coded as W—the provider cannot determine if the condition is POA—are counted as POA and thus used in risk adjustment calculations. It’s also important to note that any conditions that are coded in the 12 months prior to admission are included in risk adjustment. This includes prior hospitalizations as well as outpatient encounters.

We share these recommendations with our own clients on how to optimize mortality metrics:

• Ensure diagnoses are captured as POA when appropriate
• Ensure diagnoses capture the appropriate acuity—acute vs. chronic
• Ensure diagnoses are captured to the highest specificity possible

To avoid penalties and thrive under CMS’s HAC Deficit Reduction Act, HAC Reduction Program and Hospital Value-Based Purchasing Program, it’s critical to have a strong CDI department that works collaboratively with the quality department. In addition, thorough clinical documentation combined with accurate coding is essential to ensure correct CC/MCC assignment and appropriate risk adjustment. And lastly, now that you have this summary as a guide, don’t let all the acronyms confuse you!

By: Brett Hoggard, MD, CCDS, Chief Medical Officer, Brundage Group

Documentation and coding myocardial infarction is a common pain point for CDI departments, caused by conflicting or incomplete documentation that requires further clarification with a query. Type 2 MI is frequently incorrectly diagnosed and inconsistently documented.

To diagnose a Type 2 MI, there needs to be:

• Myocardial injury as evidenced by cTn > 99th percentile upper reference limit (URL)

• Evidence of imbalance between myocardial oxygen supply and demand causing acute myocardial ischemia (one of the criteria below):
  • Symptoms of myocardial ischemia (chest pain, etc.)
  • New ischemic ECG changes
  • Development of pathological Q waves
  • Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischemic etiology

When considering a Type 2 MI diagnosis, a common mistake is to forget about the requirement of acute myocardial ischemia. If the patient does not meet one of the criteria for myocardial ischemia, the patient should not be diagnosed with a Type 2 MI.

MI due to demand ischemia or MI secondary to ischemic imbalance are equivalent to Type 2 MI from a coding perspective. These terms map to ICD 10 code, I21.A1, MI Type 2.

Type 2 NSTEMI is a problematic term. According to coding guidelines, when Type 2 NSTEMI is documented, the code for Type 2 MI should be assigned and the code for NSTEMI should be withheld. If a coder incorrectly assigns the code for a NSTEMI – I21.4 – the case will be inappropriately pulled into the National Cardiovascular Data Registry and included in the CMS cohort for 30-day readmission rate and 30-day mortality rate.

The updated 2020 coding guidelines are creating further confusion in the accurate coding of Type 2 MI. For easy reference, here are the deletions and additions to the guidelines.

The ICD-10-CM provides codes for different types of myocardial infarction. Type 1 myocardial infarctions are assigned to codes I21.0-I21.4 and I21.9.

Type 2 myocardial infarction (myocardial infarction due to demand ischemia or secondary to ischemic imbalance) is assigned to code I21.A1, Myocardial infarction type 2 with a code for the underlying cause coded first. Do not assign code I24.8, Other forms of acute ischemic heart disease, for the demand ischemia. Sequencing of type 2 AMI or the underlying cause is dependent on the circumstances of admission. When If a type 2 AMI code is described as NSTEMI or STEMI, only assign code I21.A1. Codes I21.01-I21.4 should only be assigned for type 1 AMIs.

Acute myocardial infarctions type 3, 4a, 4b, 4c and 5 are assigned to code I21.A9, Other myocardial infarction type.

The most significant change to note is when a Type 2 MI is diagnosed, the etiology will need to be linked. The cause of the MI will be coded first. This makes sense from a clinical perspective but will require education for clinicians who don’t always document or link the etiology. And, occasionally, there are patients where the etiology of the Type 2 MI is unclear.

Education for clinical providers is critical. When a Type 2 MI is diagnosed, the clinical provider should make it a habit to document the etiology of the MI. If the provider does not document the etiology, a query will need to be issued. Overtime, linking the etiology will become a habit for clinicians, but in the meantime, expect more queries.

By: Dr. Timothy Brundage

I just returned from the ACPA National Physician Advisor Conference where I met with physicians who truly care about providing support to their hospitals.

As a key takeaway from the conference, I’d like to encourage Physician Advisors around the country to break down the silos that exist within hospital organizations. Physician advisors should be focused on much more than patient status assignment; they should be looking at the chart from a global perspective to accurately reflect the care provided. This perspective should supersede the utilization review department, the quality department and the CDI department.

The Physician Advisor should examine the chart to ensure that medical necessity is present while also ensuring the documentation supports accurate code assignment and the timeliness of the documentation supports the quality of care provided.

Only diagnoses that are captured Present On Admission (POA = Y or W) are used by Medicare to risk adjust expected mortality. The Physician Advisor should be keenly aware that mortality observed to expected rates are publicly reported. Our hospitals should provide the community with high-quality care that should be reflected as such in the metrics.

The Physician Advisor should be able to take a case review for medical necessity, which contains the documentation of cystitis and acute kidney injury with an acutely elevated Cr of 2, for example, and understand that this may or may not support inpatient status. If the Physician Advisor understands the global care provided to the patient, he or she should immediately work with the attending physician to document more effectively. If the acute kidney injury is explicitly linked to the cystitis, then the clinician should contemplate the diagnosis of severe sepsis based on SOFA.

This will immediately improve documentation that may potentially support inpatient status, support the appropriate DRG assignment to track expected resource consumption and track to the accurate expected mortality.  The utilization management team is supported, the CDI team is supported, and the quality team is supported. Most important, the accurate picture of the patient is reported—and the patient is supported!

The Sepsis-3 JAMA article published in 2016 reports a 10% expected mortality when diagnosing (severe) sepsis using the SOFA criteria.  This patient is sick, even more so than you may believe.

The role of a Physician Advisor is to support the clinician who is caring for the patient. The patient needs high-quality care and the clinician needs to be able to provide the care in the appropriate setting while also demonstrating that he or she is providing high-quality care to the community.

Physician Advisors should be breaking down the silos within hospitals to advocate for global care and global tracking of high-quality care.  They should get involved with the CDI team and the quality team, and make sure they are working with the utilization review team in a coordinated fashion.

It is not uncommon for me to go into a hospital and see the utilization review, CDI and quality teams working completely independently from one another, with very little communication.

The role of the Physician Advisor is to lead the team toward the accurate portrayal and status of the patient, as well as the appropriate tracking of the quality of care that physicians are providing to the community.

And I almost forgot to mention—this will also reduce the risk of denial if audited.

By: Dr. Timothy Brundage

Do you recall the days of being graded on a bell curve? Your grade didn’t necessarily depend on how well you knew the information and performed on a test, but rather on how you compared to your peers.

It occurred to me—after sensing nervousness from hospital administrators who watched their hospitals slip down industry ranking lists, such as U.S. News & World Report Best Hospitals—that these rankings are based on a similar curve.

According to the official announcement, “Prominent changes to the 2018-19 rankings methodology included more emphasis on patient outcomes and patient experience measures.”

You’ll never convince me that the well-respected hospital organizations that slipped down the list are no longer employing capable physicians who provide leading, high-quality care. That’s not it at all! Rather, the hospitals that top the list are focusing on CDI education, and thus documenting more effectively to support quality. The hospitals that rank lower aren’t performing worse than before—they’re just being outperformed on key metrics, such as mortality O/E.

Metrics and subsequent rankings are driven by how well your organization is documenting the entire patient tenure. If there is misalignment across the documentation spectrum, it will appear that you are underperforming, when that’s not the case at all.

Recent data—and personal observance—suggests that many programs within hospitals are designed for local vs. global optimization. For example, documentation teams are focused on optimizing the MS-DRG. Quality teams are focused on HACs (Hospital Acquired Conditions) and PSIs (Patient Safety Indicators). Utilization management teams are focused on documentation to support medical necessity. Each of these teams are effectively addressing the problems within their own space; however, they’re operating in silos. There needs to be a holistic strategy for the organization’s total performance, and each group needs to coordinate its efforts to contribute to that end.

If you’re not getting better, you’re falling behind—and you’re paying for it. There’s more urgency now than ever, as hospitals are facing a 1% penalty to revenue through CMS’s HAC reduction program. We can help! Keep up with the list leaders by keeping up with physician education, and get credit for the high-quality care you provide!