Clinical documentation improvement (CDI) efforts have been in effect within many acute care hospitals for years with the goal of optimizing reimbursement through appropriate documentation and coding. In 2007, CDI gained greater importance with the implementation of the Medicare Severity diagnosis-related group system as well as with the Centers for Medicare & Medicaid Services (CMS) requirement to document if diagnoses are present on admission (POA), with the implication of loss of payment for targeted conditions that are not documented to be POA in the medical record. Efforts to improve documentation and coding are typically managed by the HIM department and finance.
Since 2005, hospitals have also been monitoring, tracking, and reporting to CMS on numerous quality-related “core measures” as part of CMS’s Hospital Inpatient Quality Reporting (IQR) Program in order to get the full annual Medicare market basket update. Performance is measured based on documentation in the medical record. Efforts to improve performance are typically managed by the quality department.
In many hospital settings, these two functions have worked in silos with little overlap. With the advent of healthcare reform and greater consumer access to hospital quality data on publicly available websites, hospitals have now begun to see opportunity in ”coding for quality”–making sure that what is in the medical record accurately documents the severity of a patient’s illness as well as capturing care provided to a patient.
Etablished in 1997, the NewYork-Presbyterian Healthcare System (NYPHS) is comprised of 35 member institutions, including 25 acute care hospitals and 10 specialty or long-term care facilities spread across New York, New Jersey, and Connecticut. NYPHS is committed to assisting its members with applying, monitoring, and enforcing standards devised to enhance clinical excellence and patient safety. These objectives are achieved through a range of strategies, including:
- forming consensus on solutions to shared problems using clinical councils and member forums
- disseminating consensus statements and best practices through the clinical councils
- annual performance improvement conferences involving board and senior leadership and extensive non-NYPHS participation
- reporting and benchmarking of data on quality of care via a web-enabled data warehouse that analyzes data from multiple internal and external sources and provides near real-time data for decision making and planning.
In 2009, understanding the challenges of the healthcare environment, NYPHS senior leadership challenged its quality implementation team to identify innovative and cost-effective approaches to provide education, promote collaboration through best practice sharing, and provide data benchmarking support to system hospitals in an attempt to optimize coding accuracy for both quality metrics and reimbursement. NYPHS modified its existing strategies to educate a wider cross-section of hospital leaders and decision makers on the strategic importance of clinical documentation and its impact on quality measurement.
Bringing Two Councils Together
For almost 10 years, two NYPHS clinical councils–the Performance Improvement Committee (PIC) as well as a Clinical Documentation Improvement Forum (CDI Forum)–have brought together leaders in their respective disciplines four to six times each year for education, sharing of best practices, and networking. Both the PIC and CDI Forum have historically met separately with minimal overlap of council members.
What the CDI Forum Does
The goal of the CDI Forum is to facilitate enhanced accuracy of clinical documentation and medical record coding at NYPHS institutions. In addition to sharing practice strategies, the CDI Forum has been a main source of education around CMS’s recovery audit contractor program, the impact of coding on case mix index, and key elements necessary for optimizing documentation around numerous clinical conditions including pressure ulcers, falls, and malnutrition. In addition, within the past two years it has identified and benchmarked performance metrics that can be used to assess effectiveness of a hospital’s CDI program as well as highlight areas for further focus.
NYPHS conducted a brief survey that sought to find out more about the structure and priorities of CDI programs at member institutions. Of the hospitals that responded, 89 percent of hospitals reported having CDI programs, 62 percent of which have been in effect for over three years, 25 percent from one to three years and 13 percent less than one year. Eighty-seven percent of the programs are integrated into another department – health information management (42 percent), finance (28 percent), quality (14 percent), and case management (14 percent). Forty-four percent of the programs focus on Medicare patients; the remaining programs (56 percent) reported that they focused on all payers (Medicare, Medicaid, and managed care).
What the PIC Does
The system PIC consists of vice presidents or directors of quality at each system hospital as well as other quality leaders including chief quality officers and chief medical officers. The goal of the PIC is to improve patient safety across NYPHS members through assessment, resource, and best practice sharing of hospital strategies around improving compliance with CMS’s IQR program, the Joint Commission standards, and National Patient Safety Goals (NPSG). The group also works to educate quality leadership on federal and regulatory rulings that may impact healthcare organizations and to promote consensus on quality indicators and datasets for system-wide performance measurement and benchmarking. The council has surveyed its members on compliance with the NPSG, created toolkits highlighting best practice strategies for each NPSG, hosted numerous system-level educational programs, and conducted monthly virtual patient safety rounds via conference calls where hospital staff members involved in investigating and resolving patient safety issues presented a de-identified case stemming from a recent actual patient safety issue.
Both established, productive councils work in a current healthcare climate where, with greater frequency, coded discharge data are used by the federal government and other organizations to assess and report quality performance and outcomes analysis for determining quality rating and reimbursement. NYPHS saw an opportunity to move to a more integrated, interdisciplinary model for education and best practice sharing to improve the validity of patient safety metrics as well as optimize reimbursement.
In 2007, NYPHS created a web-based data portal, Comprehensive Organizational Quality Performance Improvement Technology (COQPIT), which houses data from multiple sources and allows identified system hospital users to benchmark their performance on a host of quality and outcome performance measures. Users can also identify improvement opportunities and review their data on a case-specific basis. In 2010, CDI views were incorporated into COQPIT and allowed documentation specialists as well as quality leaders to benchmark complications and co-morbidity and major complication co-morbidity rates compared to other hospitals and the system mean. It also provided the opportunity for hospitals to look at their internal data over time to identify trends and opportunities for focused review.
When the COQPIT CDI views were rolled out, documentation specialists and quality leaders were educated on the available data and potential implications through a one-hour webinar demonstration and subsequent one-on-one phone consultations. During the COQPIT calls, system hospital staff were educated on how to create CDI reports as well as how to interpret and present the data. The COQPIT calls were generally well received and provided an excellent learning opportunity for staff to manipulate their data to answer questions that they may have and use it to drive and monitor quality performance at their institutions. Usage of the COQPIT increased by 5 percent from 2009 usage rates, with 44 percent of hospitals (8) increasing their usage by 20 percent or greater.
At the system level, CDI performance data were used to identify higher performing and best practice hospitals for presentations at CDI Forum and PIC meetings as well as identify areas for system-level education and improvement. Examples of best practice presentations included one hospital’s experience with identifying, tracking, and improving AHRQ PSI 12–venous thromboembolism (VTE) prevention–by focusing on increasing accuracy of coding documentation, standardizing VTE risk assessment, documenting contraindications, and standardizing VTE prophylaxis ordering options.
Another best practice presentation highlighted a hospital’s program initiated after a CDI Forum meeting. At the January 2010 CDI Forum, council members were educated on AHRQ PSI 15 – Accidental Puncture and Lacerations, as well as issues related to overdocumenting the related ICD-9 code 998.2. System-level data were presented identifying the top 10 surgical DRGs for PSI 15 stratified by hospital for focused reviews at the hospital level. Based on the data and identified improvement opportunity, one system hospital subsequently initiated documentation improvement efforts through focused case reviews with the support and involvement of department chairs of gastrointestinal and cardiothoracic surgery.
Additionally, a second level of case review was implemented by the hospital’s HIM department in which all cases involving ICD-9 code 998.2 are reviewed prior to billing. This intervention resulted in a 34 percent reduction in APL rates from Q1 2009 to Q4 2010 (3.25 per 1,000 patients at risk to 2.15 per 1,000 patients at risk).
As an overall measure of the effectiveness of CDI efforts focused through the CDI Forum activities, NYPHS compared the proportion of cases from 2001 through 2009 that fell into the higher APR-DRG severity of illness (SOI) levels (3 or 4) for system members versus all other hospitals in the tri-state region. Increasing the proportion of high SOI cases is one way to measure improving coding of treatments and co-morbid conditions. In 2001, approximately 20 percent of NYPHS members and non-members cases were a level 3 or level 4 SOI. However, the proportion of cases that grouped to a higher-level SOI increased at a faster rate for NYPHS members–by 2009 approximately 33 percent of system member cases grouped to a higher level SOI compared to 30 percent of non-system members.
Beginning in 2009, both PIC and CDI Forum members were educated on relevant federal regulations, including expansion of CMS’s IQR program to include hospital-acquired conditions and Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI), potential components of the healthcare reform legislation and its impact on hospitals. Subsequent educational sessions included the healthcare reform legislation enacted in March 2010 and understanding and deconstructing the APR-DRGs.
COQPIT Hot Topic reports covering relevant topics were sent to hospital leadership including chief executive officers, chief medical officers, chief nursing officers, and quality officers. The reports included system data benchmarks on CDI metrics, 30-day readmission rates for pneumonia, heart failure, and acute myocardial infarction stratified by APR DRG SOI, palliative care documentation, and POA documentation rates.
In March 2011, based on the recommendation of the council chairs, NYPHS convened a joint quality and CDI meeting. More than 60 participants attended, representing a multidisciplinary group including senior executive leadership, quality, and CDI. The topics covered included presentations from a physician executive leading quality and CDI effort, an update on coding for quality and what’s at stake in the current healthcare environment, and hospital practice sharing of CDI programs and methods for physician engagement and education. The meeting was highly rated by the participants and received 9.4 for “Satisfied with education/networking” and 9.5 for “Information useful to my organization.” The top eight take-away points from the meeting were summarized and sent out to hospital chief executive, medical, and nursing officers as well as to all meeting participants.
NYPHS is planning future joint quality and documentation improvement meetings that will showcase case studies from hospitals and academic medical centers as well as community hospitals that are bridging the gap and finding success with an interdisciplinary approach to improving coding quality and improving patient safety for their patients. Identified strategies that will be highlighted include bringing a documentation improvement nurse to work in quality to provide guidance and expertise in hospital acquired condition cases and never events and identifying a CDI physician advisor to review cases, and educate other physicians on improving documentation in the medical record. For data benchmarking, we are planning to incorporate CDI metrics into physician profile reports and management reports related to quality and efficiency.
Centers for Medicare & Medicaid Services. “Hospital Acquired Conditions (Present on Admission Indicator): Statute Regulations Program Instructions.”
“Medicare Program: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule.” Federal Register 72, no. 162 (2007): 47129–48175.
Leon-Chisen, Nelly. “Coding and Quality Reporting: Resolving the Discrepancies, Finding Opportunities.” Journal of AHIMA 78, no. 7 (July-August 2007): 26-30.
Rangachari, Pavani. “Coding for Quality Measurement: The Relationship between Hospital Structural Characteristics and Coding Accuracy from the Perspective of Quality Measurement.” Perspectives in Health Information Management 4, no.3 (2007).
Marcia Brinson, MPH, RD, is manager of quality and patient safety improvement at NewYork-Presbyterian Healthcare System, New York, NY. Brian Taylor, PhD, is director of clinical analytics at NewYork-Presbyterian Healthcare System. Brian Regan, PhD, is vice president of quality and patient safety at NewYork-Presbyterian Hospital and NewYork-Presbyterian Healthcare System. Eliot J. Lazar, MD, MBA, is chief quality and patient safety officer at NewYork-Presbyterian Hospital and NewYork-Presbyterian Healthcare System. George Heinrich, MD, is chairman, board of trustees of New York Hospital of Queens.