Whose Query is it?

A reader says that coders, not CDISs, are querying physicians.

Across the archipelago of the Internet came a timid yelp to be heard one recent Thursday morning – and it has renewed a tsunami of interest and passion regarding the roles of coders and clinical documentation integrity specialists (CDISs).

A reader of last Tuesday’s ICD10monitor clicked on the “Discuss News Story” link at the bottom of a story, “The Query Conundrum,” written by veteran clinical documentation integrity (CDI) expert Cheryl Ericson. An alert appeared in my email inbox, which I dutifully clicked to open, but there was no comment there. When I responded, the reader replied, “Hi, Chuck, nothing much.” But actually, there was more to the explanation in a subsequent email.

“Our CDI department has not helped coding and documentation at all,” the reader, a coder, wrote. “The queries are primarily left up to a group of us who are not CDI, and the documentation is still mainly ‘cut and paste,’ whether it’s telling the patient’s real story or not.”

Apparently at this facility, in this department, the CDISs take “all the glory when all they do is look for diagnoses to raise quality scores,” the reader wrote, additionally noting that  “they query for (issues) such as hypomagnesemia when documentation is conflicting regarding the principal diagnosis.”

When I emailed Cheryl Ericson about this matter, she was quick to point out the obvious.

Coders vs CDISs
“There has always been and likely will always be tension between CDI and coding departments,” Ericson wrote. “It sounds like the scope of work for CDI at this organization is different than what coding thinks it should be. I would likely discuss how it is important for there to be a clear scope of work between CDI and coding, especially when it comes to querying, e.g., who queries for what.” 

Senior healthcare consultant Laurie Johnson, a regular panelist on Talk Ten Tuesdays who also files coding reports each Tuesday, and is a longtime editorial contributor to ICD10monitor, pointed out the need for both the coding department and CDI department to work together closely.

“It is difficult for the coders when the CDI staff gets all the credit for the increased reimbursement,” Johnson wrote. “It should be the team of CDI and coding. There should be a relationship between CDISs and coders so the coders can reach out with clinical questions and the CDISs can reach out with coding questions.”   

Shortsightedness
“I think both CDI and coding professionals often take too myopic of a view of the record, looking at one point in time rather than ensuring there is a cohesive, consistent story throughout the record,” Ericson wrote. “It is very important that the coded data reflects the clinical scenario. It not only impacts reimbursement, but also quality performance, so while (CDISs) at that organization may be querying for hypomag (hypomagnesemia), the Pdx (primary diagnosis) is equally important when it comes to quality scores, especially for the Centers for Medicare & Medicaid Services (CMS) metrics around HF, COPD, PNA, and MI.” 

Cutting and pasting apparently continues to be an issue at the reader’s facility, as she said that the coders were essentially charged with the responsibility, not the CDISs.

“Where I do disagree is that CDI should be the copy/paste police,” Ericson wrote. “There needs to be an organizational effort for the healthcare industry as a whole to do a better job of holding providers accountable for sloppy charting, e.g., copying and pasting and not cultivating the problem list.” 

Improvement versus Integrity
Early on, in the evolutionary times of CDI and CDISs, the focus of their work was to improve reimbursement by reviewing physician documentation – hence the term that in some facilities continue today as clinical documentation improvement. But CDI experts have lobbied hard and long to change the word “improvement” to integrity.  An early effort to change the terminology was championed by Erica Remer, MD, a former emergency room physician-turned-CDI authority and Talk Ten Tuesdays co-host and editorial contributor.

Terry Fletcher, a nationally recognized physician coder and auditor, said that each facility’s auditing department’s definition of CDI often speaks volumes.

“Which definition of CDI is the auditing department using?” she asked. “Clinical documentation improvement has been described as the process of improving healthcare records to ensure improved patient outcomes, data quality, and accurate reimbursement.”

On the flip side, Fletcher noted that clinical documentation integrity is more about “best practices” necessary to involve the correct processes, technology, people, and joint efforts between providers and coders/billers who advocate for the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g., ICD-10-CM, ICD-10-PCS, CPT®, HCPCS) sanctioned by HIPAA.

“I have seen the coder’s complaint when the focus is making sure the record is set up to maximize the physician’s reimbursement opportunities in regard to MIPS (Merit-Based Incentive Payment System) and MACRA (Medicare Access and CHIP Reauthorization Act) quality scores,” Fletcher explained. “But not paying attention to documentation integrity, to make sure that the information is accurate and not just brought forward from a previous record, since the HCCs are only reported if actively being treated. This is a big compliance issue with CDI audits.” 

Fletcher cautioned that attention needs to be paid to the current and clinical profile of the patient today, to support the encounter with the provider documented note.

“More than just counting numbers or looking for codes, the CDI managers need to look for quality within the audit,” Fletcher said. “What was captured for payment? When the documentation is accurate and complete, the positive financial impact will follow.”

Revenue and Quality
Ericson cites the adage that that revenue follows quality. But she insists that the relationship between revenue and quality has become more indirect in the last 10 years than it once was, noting that about a decade ago, if the medical record revealed a SOI 4/ROM 4, then you were increasing the “quality” impact for mortality (which is a narrow quality definition), but in order to increase the SOI/ROM to 4/4, it would take multiple CCs and MCCs (so it would also increase reimbursement). 

“Now, most risk adjustment is based on chronic conditions if hierarchical condition category classification (HCC) methodology is used, or even Elixhauser (a comorbidity software),” wrote Ericson – adding that other methodologies “include many conditions that are not CCs or MCCs, like ‘hypomag’ (except for newborns), so it does not impact reimbursement.”

Ericson reminds us the if a hospital performs poorly on Centers for Medicare & Medicaid Services (CMS) quality metrics, the facility’s overall Medicare payments could be cut as much as 6 percent – depending, of course, which programs at the facility are low performers.

“So yes, there is a lot of validity to what the coder is saying when referencing a diagnosis like hypomagnesemia,” Ericson concluded.