This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.
By Patty Buttner, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS
Healthcare providers in all patient care settings are faced with a variety of reimbursement methodologies and many are associated with a quality element.
Documentation that does not support the diagnosis and procedure codes submitted can lead to a reduction, denial, or take back of payments as well as inaccurate quality scores. No matter what the setting is, the goal of clinical documentation improvement (CDI) is to assist in ensuring quality documentation. The documentation must be reliable, precise, complete, consistent, clear, legible, and timely.
Can CDI have an impact on quality initiatives? Certainly! The core of many quality initiatives is the health record and the documentation contained within. This article will present a high-level view of some of those quality initiatives and how CDI can help with the attainment of accurate, quality documentation to support the quality initiatives.
In the acute care hospital setting, quality scores play a vital role in reimbursement and in data presented to the public regarding hospital quality. The goal is to drive quality improvement of patient care as well as cost. The data collected and submitted to the Centers for Medicare and Medicaid Services (CMS) is used to determine reimbursement based on the quality of care provided and how efficient the care was. The role of CDI would be to work with the quality department to determine a beneficial and cooperative process for the review of patient health records impacted by quality measures. It is crucial that CDI have an understanding of inpatient value-based purchasing (VBP) and the measures associated with it.
In the physician/clinician office setting, CDI can help to ensure all conditions relevant to the visit are documented. Complete and accurate documentation plays a role in risk adjustment and provider reimbursement, which is calculated in part by Hierarchical Condition Categories (HCCs). HCCs are determined by the assigned ICD-10-CM codes, which must be supported in the health record documentation. The Department of Health and Human Services (HHS) conducts Risk Adjustment Data Validation (RADV) Audits to determine if all codes submitted are supported in the health record. CDI reviews of the patient record can assist in ensuring compliance with the assignment and reporting of the HCCs.
The Merit-based Incentive Payment System (MIPS) program under Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will score clinicians on three of four performance categories in calendar year (CY) 2019:
- Improvement Activities
- Advancing Care Information
Clinicians will not be scored on the Cost/Resource Use category until CY 2020. The electronic health record is one of the listed reporting options for all but the Cost/Resource Use categories. Clinicians must report on six quality measures, with at least one measure being an outcome or high-impact measure. There are over 200 measures to select from. There is an inventory of 112 improvement activities to choose from. CDI professionals should be aware of the MIPS Performance Categories and, if working in the clinician office setting, should be versed in the measures selected for reporting. CMS provides a scoring methodology for each performance category. There are also opportunities to gain bonus points. The scores are based on a 0-100 point system. CDI can review health records of patients seen in the office and review the documentation for complete and accurate information and identify opportunities for improvement, especially if impacted by one of the performance measures.
A recent CMS blog post written by Kimberly Brandt, principal deputy administrator for operations, demonstrated that insufficient documentation errors had the highest percentage rate in CMS Improper Payment Reports. This data indicates the continued need for CDI in the ambulatory setting.
In the post-acute care setting, assessments play an important role in reimbursement. Minimum Data Set (MDS) is a vital assessment utilized in long-term care. According to CMS, “The MDS contains items that reflect the acuity level of the resident, including diagnoses, treatments, and an evaluation of the resident’s functional status.”
The quality programs for inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), and long-term care hospitals (LTCH) all have skin integrity as a common measure. These are all reported via assessments. The data is abstracted from the patient health record. CDI can review the patient health records for complete documentation and query the provider where there are opportunities for improvement. There may also be opportunities for the MDS coordinator to become educated in CDI, thus expanding the role.
As you can see, CDI certainly has a role to play when it comes to quality initiatives in many healthcare settings.
Brandt, Kimberly. “CMS’s 2017 Medicare Fee-For-Service improper payment rate is below 10 percent for the first time since 2013.” CMS Blog. November 15, 2017. https://blog.cms.gov/2017/11/15/cmss-2017-medicare-fee-for-service-improper-payment-rate-is-below-10-percent/.
Centers for Medicare and Medicaid Services. Hospital Inpatient Quality Reporting Program. CMS.gov. September 2017. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalRHQDAPU.html.
Centers for Medicare and Medicaid Services. Long-Term Care Facility Resident Assessment Instrucment 3.0 User’s Manual. October 2017. https://downloads.cms.gov/files/MDS-30-RAI-Manual-v115-October-2017.pdf.
Centers for Medicare and Medicaid Services. Quality Payment Program. https://qpp.cms.gov/mips/quality-measures.
Patty Buttner (firstname.lastname@example.org) is a director of HIM practice excellence at AHIMA.