Clinical Documentation Improvement Part 2 Flashcards
Who are qualified to serve in CDI role(s)?
HIM professionals
Physicians
Nurses
Other professionals with a clinical and/or HIM coding background
Obtain clinical documentation that captures the patient SOI and ROM
Identify and clarify missing, conflicting, or nonspecific provider documentation related to diagnoses and procedures
Support accurate diagnostic and procedural coding, MS-DRG assignment, leading to appropriate reimbursement
CDI Goals
_____________ tools can be leveraged to automate and improve documentation, coding, data extraction, and ultimately patient care.
This type of software has the ability to search and compare to assist in potential query opportunities.
It can also assist in specification and clarification of diagnoses, therefore improving the overall documentation in the patient health record.
With the advent of CAC and natural language processing (NLP) applications, history and physical reports and admission notes can be scanned for key phrases indicating the necessity for a CDI review.
Computer-assisted coding (CAC)
A calculation of the number of records that were reviewed by the CDI team. This is a good quantitative measurement of CDI productivity.This metric measures the number of records that were reviewed compared to the number of health records that were assigned to be reviewed.
Review rate metric
A calculation of the number of queries sent in relation to the number of reviews done. This gives a snapshot into the query opportunity of an organization. This would be a challenging number to have as a productivity goal. It might be best to use this number to see where you stand in meeting high quality documentation standards. If you have a productivity standard in place, it may put the team at risk of sending inappropriate queries just to reach their goal. An alternative would be to perform monthly audits on the CDI team on records. The audit could include records that have had queries sent and those that had no queries sent. This would give the auditor the ability to look for any missed opportunities and review queries for compliance.
Query Rate metric
The response rate captures how often the provider is responding to the query. This will help measure the engagement of the provider groups. You may want to break the response rate out by provider groups each month to get a more detailed picture. If you see a group with a lower response rate you may want to include the physician advisor to provide additional education to that group. This is an important measurement to take back to senior leadership to help support efforts to promote physician engagement
Response Rate metric
It is important to have timely responses to the queries for prompt coding completion. This metric will let you know how quickly a physician is responding. If you see a group with long response times, that may be an area of opportunity. This may be a metric where it would be appropriate to have a standard goal. When developing the goal, it would be beneficial to reach out to physician leaders to collaborate on a realistic goal for the providers. You may want to break down the response time by the physician groups each month.
Response Time metric
The quality and revenue impact is one of the most exciting measurements to monitor. This can give you a look at the financial gain or loss by having a CDI program in place. CDI programs should be reviewing for appropriate reimbursement regardless of the positive or negative impact. You can also pull this type of report to look at quality metrics such as PSI, HAC, SOI, ROM, and core measures.
Quality/Revenue Impact metric
The CMI is the average of all the diagnosis-related groups’ (DRGs) relative weight for a hospital. This basically shows how sick the patients are at that hospital. CMS then uses this to help calculate payments. To determine a CMI goal, the hospital will need to be compared to a hospital that offers the same types of services
Case Mix Index metric
It stands to reason that when the documentation within the health record is of high quality then the number of claims denied for missing or inadequate documentation will also decrease. The denial rate is measured by comparing the number of denied claims to the number of claims submitted. When developing a denials management team, many organizations are bringing CDI professionals into the process of determining if a denied claim should be appealed. The reasons for denials can also be used as educational opportunities for providers and staff. Denials data should also be a clue to the CDI staff on what areas of specificity to focus on in the documentation.
Reduction in Documentation-related Denied Claims metric
A physician who understands the complexities of coding, prospective payment, and third-party audits can be a valuable asset to bridge the gap in communication between CDI professionals, HIM professionals, and medical staff
Incorporating the role of physician advisor in the CDI program can benefit the facility by:
Providing in-service education regarding medical conditions, for CDI specialists and HIM coding professionals
Serving as a liaison between the health information department, the clinical documentation specialist, and the medical staff to encourage provider cooperation for complete and supportive documentation reflecting the patient’s condition
Providing education to the medical staff regarding payment methodologies, documentation requirements for medical necessity, and physician profiling
Assisting the hospital in reviewing and appealing potential coding and payment denials
Assisting with level of care determination
Physician Role in CDI
The process of reviewing physician documentation and determining whether the correct codes and sequencing were applied to the billing of the claim.
Review focuses on physician documentation and code assignment in comparison to the Official Guidelines of Coding and Reporting
Performed by a certified coder
Answers the question “Did we code it correctly?”
DRG validation
The process of clinical review of a claim to see whether or not the patient really has the conditions that were documented.
Performed by a clinician, retrospectively after claims submission
The Recovery Audit Statement of Work states this is NOT the coder’s responsibility
May result in claims denial when the clinical indicators in the record do not support the reported diagnoses and procedures.
Clinical Validation
