Guest Post: Revenue Cycle: A pertinent missing link in the CDI process

by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS

From the perspective of the hospital administration, the revenue cycle may be defined to include all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue.  Typically, this includes scheduling/registration, case management, charge capture, chargemaster, patient financial services, health information management, and revenue audit.

Frequently, clinical documentation is overlooked particularly how ICD-9 and CPT coding depends upon clear, concise, accurate, and detailed documentation in support of patient acuity, risk of morbidity and mortality, effectiveness and costs measures, and outcome and quality studies.  Complete and accurate clinical documentation serves to portray a true picture of the patient’s hospital encounter beginning with the emergency room (ER) and evolving throughout the patient’s stay within the history and physical (H&P), progress notes, consult reports, and finally a summarization within the discharge summary.

Collection of safeguarded patient service revenue is a fundamental principle of revenue cycle administration. Reference to “safeguarding” is mentioned to the extent that the risk of revenue capture recoupments by third party payers is minimized through complete and accurate clinical documentation supportive of medical  necessity and representative facts of the case that confirm physician diagnostic conclusory statements, statements that translate into ICD-9 diagnostic codes. Herein lies the limitations of our present process. We focus on CDI in a vacuum, stressing the capture of CCs and MCCs in the name of a quick win and “getting credit” for improving the case mix and “CC/MCC” capture rate.

There is more to CDI programs than the all mighty dollar, despite the fact that  the dollar is a measureable and quantifiable metric that seems to be the end all and be all for hospital administrators.

Monthly reporting of CDI program impact frequently includes:

• increase in case mix
• number of queries left by the CDI staff
• physician query response rate
• financial impact of queries
• number of records reviewed by the CDI specialists
• number of times a record was reviewed
• CDI specialist DRG congruence with final coded DRG assignment

This list reflects just the most common CDI measures. The real missing link in this analysis is an emphasis on how effective the clinical documentation is in terms of accurately depicting the medical necessity for admission and continued stay in the hospital. Medical necessity is, in essence, a function of the severity of the patient’s presenting signs and symptoms. Medical necessity is also a reflection of the number, acuity, severity, and duration of recorded patient problems, the probability of adverse outcomes, and to some extent the safety of the patient if he or she is discharged from the hospital ER without a plan for outpatient workup.

For example, if a patient presents to the ER with syncopial conditions that potentially could be worked up as an outpatient but due to patient’s history of falls, living at home without any social support, having a history of atrial fibrillation on Coumadin there is an apparent need for that patient to be admitted to the hospital for close monitoring and extensive workup for the possible causes of the syncope.

Consider the following fact about medically unnecessary short stays as evident by the RAC Demonstration project: Short hospital stays, defined as four days or less, account for 26% of the entire Medicare fee-for-service error rate while one day stays account for 11% of the Medicare fee-for-service error rate. These percentages beg the question of whether the extent of the physician’s ER H&P documentation  accurately describe the acuity via complete chronological account of the patient’s illness. Too often, the H&P documentation reads more like a “history of past illness” than the more clinically appropriate and necessary “history of present illness.”

I also call your attention to a widespread medical review of DRG 313-Chest pain, being initiated by Highmark Medicare Services, the MAC contractor for Jurisdiction 12. Highmark selected this DRG on the basis of ongoing data analysis, a Comprehensive Error Rate Testing claims error rate of 54%, and an error rate of 71% from a prior Highmark review.  Highmark stated the inpatient admissions lacked medical necessity.  Highmark, in the notice announcing this medical review,  requests the provider submit the following documentation in support of the medical necessity for inpatient admission:

• Admission and discharge summary
• Physician orders
• History and physical including documentation to support the diagnosis billed
• All progress notes including physician, nurse, and other multi-disciplines
• All test results including pre-admission testing to support admission
• Therapy treatment logs and treatment notes
• Infusion therapy flow sheets
• Medication logs
• Emergency room records
• Operative/procedure reports
• Consult reports
• Discharge assessment/plan
• Documentation to support all services billed
• Itemized bill

In this context, consider the effectiveness of the CDI initiative as a whole.  If your program is focused on the capture of CCs/MCCs and the attempt to solidify a principal diagnosis to gain a higher reimbursement level, (i.e., sepsis versus UTI, stroke versus TIA, etc.) is it doing justice to CDI from a “holistic” standpoint? By getting the quick diagnoses to appear in the progress note only once in the name of improved reimbursement, only to have the CC/MCC denied by the RAC and those monies recouped on the back end six months after the claim was billed, we negatively contribute to revenue cycle processes.

Our focus should be on solidifying the medical necessity for admission in the first place. Take the case of a patient with chest pain. CDI staff should review the entire record to ascertain and identify other possible diagnoses or etiologies of the chest pain such as unstable angina with progressive coronary artery disease (CAD), costochondritis, and unstable angina in the face of known CAD with ongoing anemia of malignancy, etc.

The goal of our chart review should be to solidfy the need for inpatient admission through accurate reporting of the patient’s H&P and acuity, number, severity, and complexity of problems that impact the patient’s risk of morbidity and mortality. Ask yourself if your chart reviews incorporate any of these elements in any shape or form.

In my opinion, the CDI profession could be embarking on a course that is headed for self destruction. We need to expand the reach and focus of CDI. Let’s jump off the perpetual treadmill of improving CC/MCC capture rates and the calculation of financial impact. While these metrics represent true to outcomes of an effective CDI program, they must remain as byproducts of our CDI efforts.

Let the focus be on the quality of clinical documentation in support of safeguarded revenue as an integral part of CDI’s contribution to effective, successful revenue cycle processes. To think otherwise merely constitutes a narrow vision of CDI!

Editor's note: Krauss, at the time of this article's release, was Executive Director of the Foundation for Physician Documentation Integrity.