How to Prioritize Clinical Documentation Integrity

Before the Centers for Medicare and Medicaid Services Diagnostic-Related Groups (DRG) started in 1983, clear and concise clinical documentation was less emphasized, however, clinical documentation integrity (CDI) now requires accurately documented severity of illness of a patient’s hospitalization. Many insurance companies and Medicare FFS are looking for specificity associated with each diagnoses. Unfortunately, CMS and commercial insurers may deny inpatient payment without specific verbiage related to the admitting principal diagnoses and secondary diagnoses. This lack of specificity can result in significant out-of-pocket expenses for the patient and a denial for the hospital.

Below are examples of specific diagnosis terminology versus generic documentation:

• Acute on chronic diastolic heart failure vs. congestive heart failure
• Acute kidney injury vs. renal inefficiency
• Gram-negative pneumonia vs. pneumonia
• Acute on chronic hypoxic respiratory failure vs. respiratory failure

COLLABORATION IS CRUCIAL
Clinical validation of the diagnoses in the electronic medical record (EMR) is the first step. Support and validation from labs, radiology, nursing documentation, and even a nutritionist-completed consult, will substantiate the indicators that support the clinical diagnoses.  However, communication is also crucial, and Clinical Documentation Improvement, Utilization Review (UR), and Case Management (CM) departments should collaborate closely. By focusing on the same patient, two potential denials, one for the inpatient level of care and one for clinical validation for the documented diagnoses, may be prevented.

Communication, or lack of, from any one of these departments, also affects the performance of the others. Transparency about the chosen principal diagnosis by the CDI specialist can undoubtedly help the UR/CM nurse with their clinical review for medical necessity. If a patient is admitted with multiple diagnoses that are similar in severity and equally treated in the eyes of the CDI specialist, a UR/CM nurse may assess the opportunity for the patient to meet medical necessity criteria referring to the other diagnosis.

These days, most denials focus on factors related to the severity of the diagnosis, the patient treatment, and the documentation to support both. Below are some leading questions teams can ask themselves to help mitigate denials.

• Does my department have open communication with the UR/CM or CDI department? If your answer is no, here are some tips from a program that had daily interaction between departments:
  • Within the EMR, create a designated tab for team visibility on concurrent work.
  • Create high visibility of the evidence-based guideline chosen that allowed the patient to “meet” for medical necessity/inpatient
  • Discuss working DRG’s as part of your daily multidisciplinary rounds with the providers and other staff members. Working DRG can be helpful and is reflective of the principal diagnosis (the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care)

TRACKING & COMMUNICATING METRICS

Leaders of the UR/CM and CDI departments should be aware of the metrics tracked monthly.
Below are key metrics specific to UR/CM:

• Observation to Inpatient conversion rates count the number of Observation patients who are converted to Inpatient.
• Inpatient to Observation downgrade rates count the number of Inpatient patients who are converted to Observation.
• Observation rate counts the number of patients who are placed in Observation.
• Length of Stay is the length of an inpatient episode of care, calculated from the day of admission to the day of discharge.
• Inpatient Denials documents the number of patient admissions that are denied for inpatient level of care payment.
• Peer to Peer Overturn and Upheld rates count the number of inpatient denials that have a peer-to-peer discussion between the insurance company and a physician and whether or not they agree with the inpatient status.
• Appeal letter Overturn and Upheld rates count the number of patient stays that are denied that have an appeal letter written to defend the inpatient status and whether or not they agree with inpatient.

Metrics Specific to CDI:

• Case Mix Index (CMI) averages of all the DRG’s relative weight for the hospital. How sick are your patients?
• Review Rate is a calculation of the patient charts reviewed by the CDI team.
• Query Rate measures the number of documentation queries sent to providers to gain clarity on diagnoses and a variety of other questions about the patient stay.
• Response Rate measures how often a provider is responding to the queries.
• Response Time measures timely responses to the queries to accurately complete a CDI review.
• Clinical Validation Denials measure several cases. These cases are denial cases due to a lack of clinical support for the patient’s diagnoses when hospitalized.

Transparency of these metrics allows both departments to see the impact of active work from a UR/CM or a CDI standpoint. Committee meetings are advised to go over the medical necessity performance metrics.  One member of the CDI team could attend to have visibility on the previous quarter’s status related to the metrics mentioned above. PEPPER results (Program for Evaluating Payment Patterns Electronic Report) should be part of the discussions to help identify areas at risk for denial.

Each denial is an opportunity to learn about the necessary documentation from a UR/CM view and a clinical documentation view. Working collaboratively as a team increases your chance of winning denials or preventing them altogether. If you want to learn more about the impact of CDI on medical necessity and the importance of collaboration, check out the Supporting Your Clinical Diagnoses for Medical Necessity webinar.

We all entered the healthcare profession to care for our patients and help them navigate the sometimes choppy waters of our healthcare system. Patient care and improving outcomes are at the core of why we advocate for fair and accurate status determinations and appropriately documented clinical diagnoses. Subscribe to the Sound blog and look out for my upcoming deeper dive into the key, trackable metrics.