CDI, Queries, Physician Engagement and Hospital Reimbursement: Every Hospitalist must know.

 As per “Guidelines for achieving a compliant query practice 2019 update” from ACDIS /AHIMA, A Clear high-quality clinical documentation, which is consistent, complete, precise, nonconflicting, and clinically valid, is essential to the integrity of the ICD-10-CM/PCS code sets.

Documentation practices could alter ‘coded healthcare data’ which get translated into ‘claims data’ which is used as a “risk-adjustment and quality of care” tool.

To maintain the high-quality documentation, queries are generated when a diagnosis is missing or when there is conflicting documentation or to know cause & effect relationship or to define acuity of a condition or whether a condition is POA or to rule in or rule out a specific diagnosis.

Queries are a permanent part of the medical record and should be retrievable in the business record. Queries should be a resource for external reviewers (e.g., the Office of Inspector General (OIG), government contractors, payor review agencies, etc.) in their evaluation of provider queries and the documentation they provide. They should be retained for auditing, monitoring and compliance purposes. Some hospitals may not be doing this.

Verbal queries also impact claims data, so these discussions are also should be memorialized or saved as queries.

How the doctors may feel about Queries? Some of the below points are true and some are not.

The more they document the more specific they would be asked to be.

The queries make them documentation specialists instead of helping them take better care of patients.

Some don’t believe queries improve quality of care.

Queries are a way to make them upcode.

Documenting minor things like Hyponatremia or Hypokalemia when Sodium or Potassium is only slightly lower than normal does not help in patient care.

It’s more clerical work.

These queries are difficult to answer the first day of their seeing the patients and also during their off time. Also, they are difficult to answer when queries are about conditions earlier in the prolonged hospital course when the particular doctor was not involved in patient care.

It’s a waste of time to document ‘Ruled Out’ in discharge summary for every differential diagnosis they mention in H&P.

Some are surprised that there are queries even on expired people.

Some [Clinical Documentation Specialists] CDS ask irrelevant questions like asking if its AKI when Cr went up for an ESRD patient.

These queries make money for hospital but does not improve patient care.

[Clinical Documentation Specialists] CDS staff make more questions to justify their jobs.

What doctors wish happen with queries?

Some hope that they are asked either leading questions or Yes/No questions to make it easy to answer queries.

Other attendings hope that coders just code from specialists’ notes/documentation and not bother them when the diagnosis is missing in their discharge summary.

How doctors actually respond to queries? They may answer on time or …

They may forget to respond or answer queries sent to them.

They may simply answer as “Unable to determine”.

They may reply saying they are off this week and will address when back next week causing delay in the process.

What hospitals are doing to improve the query process?

Making CDS staff to send Reminders via texts, emails, and also do ‘in person’ talk.

Escalation to physician advisors, medical directors or even CMO of the hospital until resolved.

Some hospitals use ‘Artifact app’ to make it easy for doctors to respond to queries.

Others are making it a part of physician bonus.

Here is The CDI education the doctors need to understand the whole process better: Inpatient Prospective Payment System:

The Centers for Medicare & Medicaid Services (CMS) assigns discharges to diagnosis-related groups (DRGs). A DRG is a grouping of similar clinical conditions (diagnoses) and the service procedures furnished during the inpatient hospital stay. The patient’s principal diagnosis and up to 24 secondary diagnoses, including any comorbidities or complications, determine the DRG assignment. Up to 25 procedures furnished during the stay can affect the DRG. Other factors influencing DRG assignment include a patient’s gender, age, or discharge status disposition.

CMS uses the DRG system called Medicare Severity DRGs (MS-DRGs).

The three levels of severity in the MS-DRG system based on secondary diagnosis codes include:

1. MCC: Major Complication/Comorbidity, the highest level of severity

2. CC: Complication/Comorbidity, the next level of severity

3. Non-CC: Non-Complication/Comorbidity, this level does not significantly affect severity of illness and resource use

CMS assigns a weight to each MS-DRG called Relative Weight [on a scale of 0-25] reflecting an average patient’s resource consumption.

Case Mix Index CMI =Relative Weight of all patients /Total number of discharges.

When the hospital submits a bill to their Medicare Administrative Contractor (MAC) for each Medicare patient treated, MAC categorizes each case into a specific DRG.

Each patient’s Reimbursement=Hospital Base Rate X RW. Based on the operating costs and capital-related costs, CMS decides Hospital Base Rate which is specific for each hospital each year. There is adjustment with added dollars to this payment based on outlier costly cases, training residents/GME, low income patients, uncompensated care, and newly approved costly technologies offered by acute care hospitals.

On the other hand, Medicare can also reduce payments if a patient has shorter LOS or if transferred to a different hospital or rehab or SNF etc.

Furthermore, the below programs also adjust the payment to hospitals.

What is Hospital Value Based Purchasing? CMS withholds a portion of payment [2%] and pays that later based on their performance on a set of quality measures including Quality/satisfaction scores/Mortality/Hospital Acquired infections/Safety/Cost reduction.

What is Hospital Acquired Condition [HAC] Reduction Program? It is a Medicare pay-for-performance program. Hospitals with Total HAC Scores greater than the 75th percentile of all Total HAC Scores (i.e., the worst-performing quartile) will be subject to a 1 percent payment reduction. The cutoff for the 75th percentile of Total HAC Scores is 0.3306 for 2020.

CMS calculates Total HAC score composed of 2 Domains.

  1. PSI [Patient Safety Indicators] 90 score=weighted average of 10 specific PSIs [including • PSI 03 – Pressure Ulcer Rate • PSI 06 – Iatrogenic Pneumothorax Rate • PSI 08 – In-Hospital Fall with Hip Fracture Rate • PSI 09 – Perioperative Hemorrhage or Hematoma Rate • PSI 10 – Postoperative Acute Kidney Injury Requiring Dialysis Rate • PSI 11 – Postoperative Respiratory Failure Rate • PSI 12 – Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate • PSI 13 – Postoperative Sepsis Rate • PSI 14 – Postoperative Wound Dehiscence Rate • PSI 15 – Unrecognized Abdominopelvic Accidental Puncture/Laceration Rate.]
  • HAI [Hospital Acquired Infections]: CLABSI=Central Line Associated Blood Stream Infections, CAUTI=Catheter Associated UTI, Surgical site infections [SSI] after Colon procedures and Hysterectomy, MRSA bacteremia, Clostridium Difficile infections [POA if it happens within 2 MN or else it’s considered HAI.]

What is Hospital Readmission Reduction Program (HRRP)? It is a Medicare value-based purchasing program. CMS bases the reduction on a hospital’s risk-adjusted readmission rate during a 3-year period. A readmission generally means an acute care hospital admission within 30 days of discharge from the same or another [Medicare-IPPS] acute care hospital.

Conditions monitored under 30-day risk-standardized unplanned Readmissions:

Acute MI, COPD, Pneumonia, CHF, CABG surgery and Elective primary THA and TKA

Conditions monitored under 30-day risk-standardized mortality rate:

Acute MI, COPD, Pneumonia, CHF, CABG surgery and CVA

What CDI programs or Clinical Documentation Specialists can do? They can…

-Provide ongoing education- Analyze PEPPER report for under or over billing practices, help hospitalists to choose appropriate principal diagnoses. Example 1: Digoxin if causing bradycardia when taken as prescribed, bradycardia is the principal diagnosis. If bradycardia is due to overdose, Drug overdose is the primary diagnosis and bradycardia then becomes a secondary diagnosis. Example 2: Document HIV only if confirmed diagnosis, don’t use suspected or probable.

-Decrease Medicare O/E mortality ratio-STEMI means 1 point each for SOI and ROM, STEMI with Left Main CA involvement means 2 points each for SOI and ROM. This is important to be low as no one wants to receive treatment at a facility where O/E ratio is high.

-help with Repeated reminders to get things done.

-Ensure accuracy of patient’s chart and Integrity of chart.

-Help increase CMI.

-Help improve Hospital and Physician profiles on Medicare Hospital compare website and Physician compare websites-UHC dropped physicians in 2014 as plans rating determines reimbursement from CMS

-Improve Severity of Illness SOI/Risk of Mortality ROM

-Improve Quality scores as they are publicly reported.

-Improve Hospital reimbursement.

-Prevent DRG-creep/upcoding to not get in trouble with FCA/False Claim Act.

-Help in capturing secondary diagnoses that ‘risk adjust‘ and exclude cases from being included in these measures. For Example: If patient has pneumonia with severe sepsis, it will remove the patient from being included in these core measures of 30-day readmission and mortality. 

Correct ‘Typos’ in Medical Records: These days all are using voice to Text dictation phones and there are typos with this. For Example: “Patient got stent in Vermont” was wrongly interpreted as “Patient got stent in Walmart.”

Overall, CDI can help in capturing an accurate picture of patient-care provided and resources used for getting appropriate reimbursement.

What should hospitalists be told?

-Hospitalists should document all the symptoms the patient tells in H&P. So that, if a new diagnosis is found later after further testing, it can be related to these symptoms and POA can be assigned to those new diagnoses.

Both principal diagnoses and secondary diagnoses should have one of the below Present on Admission [POA] status: All claims involving inpatient admissions to general acute care hospitals or other facilities are subject to a law or regulation mandating collection of ‘present on admission’ information. POA is defined as “present at the time the order for inpatient admission occurs“. The conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.

Y = present at the time of inpatient admission

N = not present at the time of inpatient admission

U = documentation is insufficient to determine if condition is present on admission

W = provider is unable to clinically determine whether condition was present on admission or not Principal diagnosis must be present on admission.

Document Diabetes with its manifestations linked for ICD10 coding.

Hospitalists should be aware that the principal cause of denials is inappropriate or incomplete documentation.

Recovery auditors from Medicare usually target records with only one CC or MCC for auditing. So, try to document all the medical conditions the patient has as they may contribute to more CCs and potentially MCCs.

CDI team can send retrospective queries asking to include results of path reports, which come back after discharge, in discharge summary. Hospitalists should comply with this request.

If there are too many queries, [Clinical Documentation Improvement Specialists] CDS staff can meet doctors in person to clarify them instead of sending too many queries online. Hospitalists should help them with clarification.

Hospitalists should make sure to document clinical indicators to support certain diagnoses especially severe Malnutrition, sepsis, acute respiratory failure etc which are under scrutiny. 

Hospitals are resorting to Open charts system which means patients can access physicians’ notes as soon they are signed in the chart. So improved documentation is mandatory.

5 Star hospital quality ratings for hospitals are based on 70 distinct quality metrics among 7 major categories which include Mortality [22%], Readmissions [22%], Safety [22%], Patient Experience [22%], Effectiveness of care [4%], Timeliness of care [4%] and Efficient use of medical imaging [4%]. It is important that these quality metrics are kept in mind while documenting.

How to improve Hospitalists’ Engagement?

Words both written and spoken are very powerful.  Effective communication is key. Having the necessary information given above on hand changes perspective for hospitalists.

All hospitalists are leaders. They should think like leaders.

Dyad Rounding with nurses: It has several benefits like less texts/pages, increased patient satisfaction scores, decreased medicolegal issues etc. Hospitalists should try to see every patient along with nurses.

Multiple people read physicians’ notes. At least 20 people in some cases. An accurate medical record by hospitalists is very important.

There is a difference of several thousand dollars in payment between ‘observation status’ and ‘inpatient status’.

Physician Advisors and CDI people do a lot of desk work prior to reaching out to the hospitalists either with status change requests or with queries. So, it’s very important to work with them in a timely manner.

Not only patient care but it’s equally important for hospitalists to support hospital finances, quality scores, accreditation etc.

When quality measures are not met, hospitals are dinged not physicians. So, hospitalists should understand the efforts of the hospitals and support those efforts.

Physicians should not just say ‘NO’ but come up with solutions and be part of the solution.

Support Physician Advisors by writing that Compelling Reason in the chart for the patient to stay another night in the hospital when not discharging that day. Date wise listing of events and procedures is also very helpful for physician advisors to help with denial management

Progress notes should reflect day to day progress of the patient’s medical condition clearly.

When certain conditions are diagnosed like Sepsis, Severe malnutrition, Acute respiratory failure, etc, make sure to document appropriate clinical indicators supporting those diagnoses.

Document every condition the patient is diagnosed with. It helps in improving CMI, risk adjustment etc.

Conclusion: CDI program is the back bone of the hospitals’ finances and high-quality care for patients. Hospitalists have a major role to support this. Please document well to minimize queries and also answer the queries on time.

Read here to know “How to ace the CCDS exam conducted by ACDIS?

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