Revenue Cycle, Health Data

Seven Essential Steps for Successful Second Level Review Programs in Coding and CDI

The notion of second level reviews is firmly established across various industries, including healthcare. Whether it’s nurses double-checking insulin levels or smartphones employing two-factor authorization, the principle remains the same: A second set of eyes enhances accuracy and reliability. Within health systems, both coding and clinical documentation integrity (CDI) teams conduct second level reviews.

The focus of second level reviews in coding and CDI is to ensure the clinical truth of a patient encounter is accurately documented, supported, captured, and coded. For example, CDI teams use second level reviews to identify documentation that may be missing within the electronic health record (EHR) for the patient’s encounter. Coding departments conduct them to assess codes that may be absent based on the existing clinical documentation. Both teams work together to ensure accuracy and completeness of clinical documentation and coding.

When executed well, the value of second level coding and CDI reviews is easily cost-justified by senior leadership in hospitals and health systems. The added set of eyes not only benefits the health system, but also demonstrates the true value within coding and CDI teams.

Justifying Cost of Second Level Reviews

Second level reviews, when done correctly, offer many benefits, including revenue protection, accurate reimbursement, improved expected mortality, proper risk adjustment, enhanced quality ratings, and an overall opportunity for further staff education and accreditation.

Beyond financial benefits, second level reviews positively affect each health system’s reputation as a provider within the community. It is important to convey this outcome to leaders, emphasizing the long-range value of second level reviews.

The return on investment is typically $5 saved for every $1 spent as programs find dollars left on the table, track them, and produce overall value over time. New workflows improve IT operations and information sharing as the patient intake process becomes smarter and more accurate. Expanded education for CDI, coding, quality, and physician teams also boosts organizational efficiency and creates a more complete patient encounter story.

The onus is on the coding and CDI leaders to build successful second level review programs, implement best practices, and effectively communicate program value to executive teams for endorsement, approval, and ongoing support.

Considerations for Second Level Review Programs

Even with effective CDI and coding programs in place, continual improvement and education are imperative. Health system leadership must recognize the inherent value of second level reviews and support implementation or expansion.

However, coding and CDI department leaders and staff must advocate for the resources needed to conduct reviews effectively and cost-justify them upstream. Here are three important considerations:

The Right Team Matters

A critical component of second level reviews is the ability to tap the right coders or CDI specialists for the job. Whether assigning the reviewer role to an internal team member or outsourcing additional staff, the following requirements are recommended:

  • Tenured and proven experience with broad knowledge
  • Experienced with risk adjustment methodology
  • Collaborative and able to work well with existing CDI staff, coders, quality, and provider teams

Types of Second Level Reviews

There are many variations of second level reviews. Choosing the best option for your organization depends on goals, available technology, and applications currently in place. Here are the most common and successful types of second level reviews.

Mortality Review

Second level mortality reviews aim to improve APR DRG severity of illness and risk of mortality scores and observed to expected (O/E) ratio. These reviews benefit from a comprehensive approach that applies consistent criteria to all patients and comorbidities, enhances risk adjustment, and positively impacts publicly reporting data, including mortality measures, Star Ratings, Healthgrades, and U.S. News & World Report rankings.

Quality (PSI and HACs)

Reviewing Patient Safety Indicators (PSIs) and Hospital-Acquired Conditions (HACs) begins with validating appropriate flags and coding according to inclusion criteria. Addressing exclusion criteria through queries can prevent unnecessary PSIs and HACs, reduce Medicare fees for service discharges, and improve publicly recorded data.

Targeted DRGs and Denial Prevention

These reviews ensure accurate reimbursement by validating comorbidities and complications and addressing DRGs at risk for audits or denials. By capturing missed diagnoses and enhancing documentation, systems can mitigate denial risk and support accurate reimbursement.

Readmissions

Reviews regarding the Centers for Medicare and Medicaid Services (CMS) Hospital Readmissions Reduction Program focus on principal diagnosis assignment and risk adjustment for unplanned readmissions. These reviews demonstrate the value of CDI by improving care coordination and reducing avoidable readmissions, factors that impact payment under the program.

CDI/Coding DRG Mismatch Reconciliation

This second level review reconciles discrepancies between CDI-assigned DRGs and final coding, ensuring accurate documentation and code assignments. Collaboration between CDI and coding teams is critical to facilitating future-based education and proper reimbursement.

Publicly Reported Data

Most second level reviews ensure proper reimbursement and impact a health system’s publicly reported data. If your organization’s overall goal is to improve this publicly reported data, your second level review should validate present-on-admission status and revise top diagnoses lists to include all risk-adjusted codes. This will ensure accurate claims data for quality initiatives and publicly recorded data.

Special Projects

Customizing reviews based on organizational objectives for the second level review can provide a concentrated process supporting your facility goals and objectives. For example, addressing a recent pain point that requires CDI assistance or conducting a pulse check on new offerings, procedures, or implementations.

When implementing or considering a second level review for your organization, leaders must encourage tracking and trending findings that are identified. Sharing outcomes of second level reviews with coders and CDSs supports education, awareness, and the value of clinical documentation improvement teams.

Technology Supports the Program

Many health systems have invested extensively in CDI tools and EHRs. These technologies are valuable partners to support the second level review process and workflow. Here are our recommended qualifications for using your current or potential technology:

  • Ability to create customized work queues
  • Use of edits and flags within the system to identify appropriate reviews
  • Track-and-trend capability to determine educational needs of coders or CDI specialists
  • Customized reporting

Best Practices Inform the Process

Second level reviews offer important benefits to CDI programs and their health system. But if not set up efficiently, they will not provide the immense value available to the organization.

Learning from successful implementations and adopting proven best practices support the justification and implementation of valuable second level reviews within healthcare organizations.

Seven Steps to Build a Thorough Second Level Review Process

In working with healthcare organizations nationwide, the following seven steps are proven to yield success for second level review programs.

  1. Collect and review data. Use your current data to establish a baseline — the value programs could potentially bring to the organization — and continually assess data to show the value ultimately delivered. Start by highlighting your pain points. This could include below normal CC or MCC capture rates, Pepper Report problem areas, common clinical and DRG denials, high volumes of Patient Safety Indicators (PSIs) and Hospital-Acquired Conditions (HACs), or poor grades on publicly reported data websites.
     
  2. Consider a focused third-party audit. If internal data is lacking, third-party audits can prove beneficial for implementing a second level review process. They can also guide your team’s efforts. Once you establish your data’s source of truth, you should employ an internal or outsourced individual who will be responsible for monitoring this data.
     
  3. Select a few target areas. Start small and expand further after proving success. Consider conducting a pilot test as a low-cost demonstration to sell your leadership on implementation and showcase a return on investment.

    Be sure you know the value of each target area. Consider each area closely before adding to your list. Second level reviews can quickly overwhelm coding and CDI teams, disrupt workflow, and unintentionally oversell potential outcomes.
     
  4. Develop your process and communicate. Begin drafting your team’s workflow to establish a streamlined process and ensure clarity regarding individual responsibilities and roles. Effective communication is essential for smooth operations and workflows.
     
  5. Assess impact on Discharged Not Final Billed (DNFB). DNFB is the most common pushback against second level reviews. The process must not cause significant billing delays. To mitigate delays, create a timely query escalation process and wait a few days post-discharge to ensure all patient encounter data and charges are captured.
     
  6. Establish and monitor new metrics. As part of a thorough second review program, create a process to track and trend new data points. These include areas that need proper interventions, further review, and staff education. Consider monitoring the following:
  • Impact on all second level reviews when queries are sent (DRG, CC/MCC, SOI/ROM, HCC, Elix Hauser, etc.)
  • Original CCDS and coder outliers
  • Query topics for further education
  • Top DRG changes
  • New providers and specialties
  1. Develop and deliver education. Whether you conduct the reviews internally or enlist help from a third party, it is crucial to convey the findings and educate your teams to ensure organizational success. Share the review outcomes with clinical documentation specialists, coders, and providers to foster ongoing education and improve documentation clarity.

    Finally, a best practice is to provide the results and newly developed queries each month to address the previous month’s findings. This promotes collaboration and continual system-wide improvement. Moreover, it supports the expansion of second level reviews to new areas over time.

Perfecting Programs Takes Time and Focus

Building and implementing second level review programs has yielded valuable lessons learned for healthcare professionals.

When implementing the second level review process, Carolyn Bauer, MD, medical director of clinical documentation at Montefiore Medical Center in New York, faced difficulty pulling individuals together to build a second review team. Specific challenges included varying levels of expertise and mixed understanding of the program’s potential value.

Bauer suggests HI leaders ensure teams know the value of these reviews, the potential for reduced administrative burden, and new opportunities for upskilling their careers. To perfect programs, Bauer suggests the following strategies:

  • Work with IT to streamline workflows and implement new processes to expedite transfer of vast amounts of data and information exchange across the team. 
  • Reiterate the need for patience with DNFB timelines as the program matured and inpatient and outpatient benchmarks improved. To do this, Bauer prioritized completeness and accuracy over timeliness. Instead of rushed bills and subsequent rebilling, the team focused on taking time upfront to ensure no back-end flags were raised with the payer resulting in denial, audit, or recoupment.
  • Prioritize PSIs and HACs. These cases are included in your health system’s publicly reported data and may result in long-term negative financial repercussions. If a diagnosis code has present on admission (POA) marked as “no,” then PSI or HACs are probable. To avoid the risk, ensure a consistent and clear collaborative approach between quality, coding, and CDI.

Finally, savvy HI leaders use technology as copilots to support their second level review teams. Machine learning tools may include criteria to pull specific cases and place them into work queues. Systems with enhanced technology also provide the ability to pre-scrub cases and route to reviewers. However, when using technology to support second review programs, always rely concurrently on human intervention to ensure proper usage and view the entire process.

 

Kristy Evans, RHIT, CCS, CRC, CPS, is an industry-recognized advisor in auditing, coding, education, and CDI. She has led top-performing revenue cycle transformation with major health networks and worked with global and domestic teams to ensure performance outcomes are exceeded and offering her technical and subject matter expertise. Evans currently serves as vice president of solution design at e4health, building trusted partnerships with clients.

Staci Josten RN, BSN, CCDS, currently serves in CDI consulting leadership roles at e4health, overseeing CDI professionals and developing and implementing CDI projects. Over her extensive 25-year career in healthcare, she has held regional and national CDI director titles at a large health system.

 

Tags: coding , readmission rates , data integrity , workforce development , quality reporting , clinical data integrity , training , second level review