Has your organization launched a clinical documentation improvement (CDI) program? Developing a detailed CDI program is an essential component of a successful transition to ICD-10. Providing documentation education prepares clinicians to adjust documentation practices in order to capture greater specificity in patient records, and it prepares other medical professionals for impending changes. By helping your organization improve how it documents care, you will minimize delays at the ICD-10 go-live date, which recently was revised to Oct. 1, 2014 by a final rule issued by the U.S. Department of Health and Human Services (HHS).
While some organizations are ahead of the curve with their documentation improvement efforts, others have yet to implement a CDI plan at all. However, those in the early stage of program implementation shouldn’t view this as a negative, because organizations just getting started have an advantage in that they do not need to break bad habits (such as accepting less-than-optimal documentation and allowing “unspecified” as a default instead of identifying and applying an accurate code).
If you do not have a CDI program in place, now is a good time to begin, even considering the recently announced implementation delay. If you are further along with your CDI program, there are things you can do to make the task of updating your documentation improvement plan relatively easy to manage.
Creating a CDI program without breaking the bank
First, you must establish goals for your program.
The point of entry for a CDI program involves identifying documentation that supports a specific code assignment. Concurrent and retrospective chart reviews can support consistent documentation practices and ensure that clinicians document with the appropriate specificity.
Performing concurrent reviews – reviewing patient charts while the patient is still in the hospital as part of an inpatient stay – is beneficial because of the immediate impact on reimbursement. Conducting concurrent reviews ensures completeness and accuracy of the record at the time of service, making the record ready to be coded and billed properly as soon as it can get through the workflow.
With retrospective reviews, the final MS-DRG cannot be determined until after the coding process is completed. However, if clinicians aren’t properly trained in documentation specificity, this can result in additional queries and lead to a growth of DNFB – and it also can create additional work and complicate the process of processing clean claim submissions, at times preventing the possibility of getting reimbursement right the first time.
The goal is to have the most accurate and specific clinical documentation possible. So determining the method you will use and how you will educate clinicians are appropriate things to consider when establishing program goals that will be foundational keys to success for improving or creating your clinical documentation plans.
Do your own research
Take the steps to analyze your case mix and to audit your existing high-dollar, high-volume, high-risk procedures and diagnoses. Rather than review all records, set a goal for what is a reasonable sample size.
It is recommended that providers review your top 20-30 DRGs and procedures, as well as at least 10 percent of those records. Planning to do this will provide a reasonably accurate estimate of the resources needed for your program. And by using an appropriate sample size, this can provide insight into the quality of existing documentation and where there is opportunity for improvement.
Understand the differences in the coding systems
While some documentation elements will stay the same in ICD-10, such as the need to document laterality consistently, other documentation requirements will change. For example, ICD-10 will require more detail in terms of how and where an injury happened and the visit type (such as initial, subsequent or sequelae).It is important to understand these differences and how they impact code assignment.
One way to improve CDI efforts is to leverage information shared by the medical community. Take time to read professional journals on documentation issues to develop strategies and learn how your peers are navigating challenges. Identify the most knowledgeable ICD-10 staffers in your organization and tap into their insight to get a better understanding of what is different so it can be communicated to physicians and other medical professionals.
Looking outside your organization in other ways can be beneficial as well. Network with your peers and contact the American Health Information Management Association (AHIMA), the Association for Clinical Documentation Improvement Specialists (ACDIS) and/or your local component health information association to see what tools they have available for use. If you don’t have internal resources, don’t hesitate to contract out some audit and development work.
Know your case mix
Focus education efforts on your top 20 diagnoses or conditions. Start by conducting research to determine specialty-specific required changes and focus education on those areas, as well as on CCs and MCCs.
Just 5 percent of the nation’s population account for nearly half of total healthcare expenses in the U.S. As such, education efforts should center on patient conditions that are ranked among the Top 20, and the most prevalent in your organization, because they will be representative of your top documentation issues as well.
This is another area where, if you do not have appropriate internal resources, you should consider working with an experienced consulting company that provides documentation education. The right resources can help you analyze your case mix and its impact on reimbursement.
It is also important to understand your threshold investment, which will help you determine the most cost-effective assignment of resources. By understanding financial exposure, organizations can allocate resources better and determine how long they will need to be in place. Also consider rotating resources through various departments to extend the reach of your program and to ensure that all coding options are covered.
Facilities with the luxury of ample resources can cross-train CDI or CDI-type resources to manage workflow better and to increase the knowledge of experts. Because specificity impacts reimbursement, it’s important that expert resources are sophisticated and knowledgeable in their required specialties.
Tap into the expertise of the right specialist
Physicians may not want coders to tell them what to do, but well-qualified professional coders can help your clinicians improve documentation just as well as the most seasoned physicians. Certified coders are trained to understand what needs to be in or out of documentation.
While AHIMA recently announced the launch of a clinical documentation improvement specialist certification program (ACDIS has had one for years), it is not the only qualification to look for when selecting a staff resource. Look for years of coding experience and coding expertise within your desired specialty.
It’s time to do something
Organizations with a program in place can promote the creation of more accurate records and ultimately deliver better care to patients. Improving clinical documentation requires a commitment, but implementing a successful education program doesn’t need to break the bank.
Whether you’re just getting started or looking to increase the effectiveness of your existing program, the sooner you begin, the better prepared your organization will be. It just requires doing something – planning, learning and/or executing.
About the Author
Veronica Hoy, MBA, is vice president of the HealthSERVE Consulting unit of SourceHOV. Veronica has been an operating executive for more than 10 years, focusing on providing strategic leadership and direction to healthcare professionals and organizations. She has more than 20 years of healthcare experience in business process outsourcing, accounts receivable management, coding, billing, release of information, consulting and systems implementation.
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 Center for Healthcare Research & Transformation, Healthcare Cost Drivers: Chronic Disease, Comorbidity, and Health Risk Factors in the U.S. and Michigan, July 2010