Back to Basics: Returning to a Revenue Focus with CDI Efforts
In the early days of clinical documentation integrity (CDI), the focus was on revenue capture for the Medicare fee-for-service (FFS) population due to the introduction of Medicare Severity Diagnosis Related Group (MS-DRG) reimbursement methodology. The shift to MS-DRGs allowed payments to be stratified across up to three groups of patients based on their expected resource consumption as determined by reportable diagnoses, how they were sequenced, and if there was a reportable procedure.
As CDI departments became more common, some facilities in the industry started shifting to reviewing all MS-DRG payers and eventually to reviewing all patients. There were several primary reasons that contributed to this population shift. The first was to avoid being “leading” or “noncompliant” because there was a perception that focusing only on Medicare FFS patients and accurate reimbursement was somehow improper.
The Hospital Inpatient Perspective Payment System (IPPS) rule of 2008, which introduced MS-DRG methodology, states:
“We do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.”
Of course, the key here is ensuring the medical record includes supportive documentation, which is often the purview of CDI professionals. It is not a compliance issue for CDI departments to review a subset of patient populations, which may be determined by payer, diagnosis, or even provider. Hospitals are not mandated to have a CDI department. CDI professionals are an additional tool that can improve the accuracy of patient acuity reflected in claims data by helping bridge the gap between clinical documentation “physician-speak” and coding requirements.
The Centers for Medicare and Medicaid Services (CMS) only requires diagnoses and procedures that impact payment to be accurately reported. It is perfectly compliant for CDI departments to only focus on verifying assignment of the principal diagnoses and those diagnoses and procedures that impact MS-DRG reimbursement methodology.
As staffing becomes more of a challenge and hospitals experience more financial stress, it may be necessary for CDI departments to scale back their workload. One way this can be accomplished is by reducing the volume of subsequent reviews.
Not all MS-DRGs have the same financial opportunities or the same impact on CMS quality-of-care measures. Reviews that should be prioritized are MS-DRGs at risk for improper payment according to CMS analysis such as Comprehensive Error Rate Testing or Office of the Inspector General targets and those most at risk for payer denial as well as those that yield the most financial opportunities. Data analysis can be used to identify MS-DRGs that do not require queries, or do not result in denials, or are not included in a quality-of-care population so they can be excluded from subsequent CDI reviews.
All Payers, Patients Don’t Yield the Same Financial Opportunities
Another reason for the shift to reviewing all patients and payers was the desire of hospital leadership to capture additional revenue. The hope was more CDI reviews across a broader population would result in even higher revenue. Unfortunately, some populations just don’t have the same return on investment as others due to the lack of acuity within the population or their associated payment methodology.
Many state Medicaid plans and Maryland use the All Patients Refined Diagnostic Related Groups (APR-DRG) methodology, where payment is based on the associated severity of illness (SOI), which can range from a value of one to four. However, the pediatric and maternal population are often excluded from the CDI review population, except for hospitals that specialize in this type of care, as they tend to be more homogenous than the Medicare population and yield less financial opportunity.
The bottom line is neither all populations nor all clinical conditions have the same financial opportunities. Does it make sense for CDI staff to review all patients, or should there be a specific strategic rationale, e.g., quality-of-care measures, increased denials, etc., or data that demonstrates an acceptable level of financial opportunity to include a population?
Does a Quality Approach Require Review of All Patients and Payers?
Lastly, the quality movement has also contributed to increasing the CDI review population. Even though MS-DRGs can stratify patients in up to three groups when diagnoses classified as complications/comorbidities (CC) or major complications/comorbidities (MCCs) are reported on a claim, MS-DRGs are not used as a risk-adjustment methodology for CMS mandatory quality programs, including the Hospital Value Base Purchasing Program, Hospital Readmission Reduction Program, and Hospital Acquired Conditions Reduction Program.
As CMS incorporated value-based reimbursement methodology, the agency moved from abstracted quality data to collecting it from claims data. This shift created a relationship between performance on quality measures, like mortality, and claims data used for reimbursement.
In the early days, the primary risk adjust methodology was the SOI and risk of mortality (ROM) score associated with the assigned APR-DRG. To maximize the SOI/ROM of case usually required the presence of multiple diagnoses classified as CCs or MCCs, but to maximize the MS-DRG only required the presence of one CC or MCC, depending on the type of MS-DRG (e.g., single, pair, or triplet). Consequently, the same strategies that increased expected mortality rates (e.g., increasing the SOI and ROM) also resulted in higher reimbursement under MS-DRG methodology. It was easy to focus on quality and incremental revenue.
As quality metrics mature, data analysis has allowed further refinement of risk methodologies that vary by patient population and diagnosis. The generic approach of increasing SOI/ROM on every claim no longer has the same impact on expected mortality rate as measured by CMS quality metrics. The population included in these quality programs is still defined by a particular MS-DRG, diagnosis and/or procedure, but the primary risk adjustment tool is the CMS hierarchical condition categories (HCCs).
There are also a variety of organizations that rank hospital performance like US News and World Report, which incorporates Elixhauser variables for risk adjustment. Both CMS-HCCs and Elixhauser methodologies incorporate chronic diseases that are not as likely to maximize SOI/ROM or the MS-DRG. There is only about a 60 percent crossover rate of diagnoses that can impact both MS-DRG and CMS-HCC assignment. As a result, it now takes additional CDI time and resources to review a record to accomplish both objectives.
Avoiding Revenue Cycle Redundancy and Increasing Effectiveness
The result of trying to capture all “impactful” diagnoses is turning the CDI professional into a concurrent coder, creating redundancy in the revenue cycle. The CDI professional no longer focuses on a subset of patients or diagnoses, making it harder to distinguish their role from that of the coder except that most CDIs perform their reviews concurrently, while coding is usually a retrospective activity.
Perhaps it is time to rethink CDI and coding collaboration and move toward a model of concurrent coding. Or maybe it’s time to go back to basics and, rather than trying to “boil the ocean,” allow the CDI staff to focus on those populations, payers, providers, MS-DRGs, or diagnoses that yield the most return on investment to accomplish organizational goals. With all the data available to healthcare organizations, there must be a better way to identify where CDI efforts should be focused to avoid dilution of the department’s impact.
As resources become increasingly scarce, it is imperative CDI departments examine their current activities to see if it is helping the organization accomplish its key performance indicators. Is business as usual achieving the same financial impact as it did when the department was created? What about the same financial impact as five years ago? How is your CDI department performing year-over-year adjusted for COVID?
It's time to get back to basics. What is the primary purpose of the CDI department at your organization? Is it revenue enhancement or performance on CMS quality-of-care measures or performance on other quality measures? Do all CDI professionals on your team need to perform all functions? Would there be more efficiency if CDI staff were specialized where, for example, some focus on high-risk quality populations, some on high-risk revenue populations, etc.? How do CDI functions at your hospital translate into daily tasks that drive organizational success on key performance indicators? Are better results truly achieved with higher volumes of reviews across the whole population with multiple reviews for each record? Is what we as an industry are currently doing continuing to yield desired results?
Be careful of the “we’ve always done it this way” mentality as the economics of healthcare continue to change. As a profession, we must adapt and change, too.
There is no federal, CMS, or professional organization guidance that requires CDI departments to review all patients across all payers or perform multiple reviews during a hospital stay. What is the best practice to accomplish your organization goals?
CDI is a supplemental business function. Consider redefining the role of CDI as a tool to reduce revenue leakage in addition to revenue enhancement. Focus concurrent CDI resources on records at risk for improper payment, including denials to prevent revenue leakage and to promote risk adjustment to protect revenue under value-based purchasing methodologies. Leverage analytics to identify those MS-DRGs where CDI reviews are most likely to result in organizational success. Often, less is more, and quality yields better results than quantity.
Cheryl Ericson, RN, MS, CCDS, CDIP, is the director of CDI, utilization management, and case management at revenue cycle management solution provider Brundage Group.