CDI Gains Prominence Under Payment Reforms

The Centers for Medicare and Medicaid Services (CMS) goal of tying 90 percent of reimbursement to quality improvement programs by 2018 means clinical documentation improvement (CDI) initiatives are going to be central to helping organizations succeed in the alphabet soup of reforms.

In the keynote presentation titled “Understanding the Continued Evolution of CDI” during the second day of AHIMA’s Clinical Documentation Improvement Summit, Cheryl Ericson, MS, RN, CCDS, CDIP, from DHG Healthcare, said providers need CDI to “keep up with the Joneses” due to this change in reimbursement.

Prior to the reforms that came out of the Affordable Care Act—such as hospital value-based purchasing (HVBP), the Hospital Readmission Reduction Program (HRRP), inpatient quality reporting (IQR), and the Hospital-Acquired Condition Reduction Program (HACRP), to name a few—quality efforts were focused on studying and reducing mortality, Ericson explained. Quality is now being linked to reimbursement, which hinges on proper clinical documentation.

Ericson continued by pointing out some of the changes the industry is already starting to see. These changes include:

  • Healthcare is not as lucrative as it used to be, as evidenced by the fact that length of stays are growing ever shorter. Admissions for conditions such as transient ischemic attacks (TIAs) used to be “cash cows” for hospitals—now those patients are being admitted for observation and moved along the continuum. As Ericson noted, “Higher revenue is no longer associated with higher volume” in the transition away from fee for service.
  • As a result of shorter hospital stays, providers should see their case mix index (CMI) increase and expected mortality will look different too, as only the sickest patients will be treated in inpatient settings.
  • There is more of a focus on outpatient CDI because while outpatient services have lower revenue attached to them, there is a much higher volume of claims.
  • When hospitals are treating Medicare patients, they’re losing money, so there is pressure to do more with less.

Ericson said that Medicare’s Comprehensive Care for Joint Replacement Program, which requires providers to complete joint replacement procedures and the needed rehabilitation and after care within 90 days for a lump sum, is a sign of things to come. She predicts that as a response, large organizations may dedicate whole CDI teams to making sure these encounters are well-documented to meet compliance.

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