Excerpted with Permission from For The Record
January 2018, Vol. 30 No. 1 P. 14
by Lisa Eramo, MA
In the past, CDI programs were focused on queries that directly increased reimbursement. Now, some programs have expanded that scope to include queries that impact quality and risk adjustment—two big factors in value-based purchasing. But have program performance metrics evolved to reflect these new goals?
Not quite, says Fran Jurcak, MSN, RN, CCDS, vice president of clinical innovation at Iodine Software. “We talk about the increased scope of practice, but then we still hold our employees accountable to the same metrics we used 10 years ago,” she says.
Glenn Krauss, RHIA, BBA, CCS, CCS-P, a senior consultant at Federal Advisory Partners, agrees. “The problem with programs today is that they’re based on invalid and unreliable measures of CDI. The fact that you touched a record, left a query, and received a documented clinical condition in the chart doesn’t necessarily mean you have improved documentation,” he says. “Solidifying a diagnosis in and of itself does not constitute CDI. What really matters is the quality and completeness of documentation that best communicates the patient care.”
Why haven’t programs moved beyond the basic key performance indicators? Krauss says it all goes back to revenue. “Can you sell a program to a CFO based on the quality of the documentation? You can’t,” he says.
Hospital CFOs need to understand the long-term effects of documentation, says Tiffany McCarthy, RHIT, manager of HIM solutions at GeBBS Healthcare Solutions. Even if organizations gain revenue in the short term, what happens when documentation indicates that outcomes are consistently poor? Insurance base rates could decrease, causing a loss of millions of dollars the following year, McCarthy says.
It’s irresponsible for organizations to continue to rely on traditional key performance indicators during the shift to value-based reimbursement, Krauss says. Episodic reimbursement necessitates the need to improve documentation quality across the board—not simply to shift a single DRG, he says.
Organizations also must contend with publicly available quality ratings. When consumers see that an organization has poor outcomes, they may seek care elsewhere, McCarthy says. “We’re in the age of information, and more and more people are using this information when they seek care,” she says.
How should today’s CDI programs define success? Krauss provides the following metrics:
- low rate of hospital-acquired conditions;
- low rate of patient safety indicators; and
- decreased medical necessity denials (ie, denials due to insufficient documentation).
Organizations with quality-driven CDI programs also can measure success through a lower conversion rate from observation to inpatient status, Krauss says. That’s because these programs drive quality documentation from the onset of the patient encounter, helping to establish a reasonable expectation that the patient will stay at least two midnights.
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