Guest Post: Why CDI efforts should matter to patients and physicians, part 2

by Melinda Tully, MSN, CCDS, CDIP

My last blog post focused on physician profiling. Time and time again, I’ve seen that once physicians understand how clinical documentation impacts their pay, profiling, medical/legal risk and severity of illness reporting, they realize it is in their best interest to learn the key elements of clinical documentation improvement (CDI), and how that applies to ICD-10.

As we all know, it’s not just physicians getting a grade. Whether it’s Healthgrades, Hospital Compare or Consumer Reports’ Hospital Ratings feature, it is easier than ever to search and find scores for hospital performance. Finding a quality physician or hospital has become as easy and simplified as searching for a favorite restaurant online.

Hospitals and health systems need to make sure their ‘grade’ online is a true reflection of performance. And since that grade is derived from coded data and abstracted from quality measures, CDI has yet another role to play in setting the record straight.

Perhaps the most significant transition facing hospitals is value-based purchasing (VBP). Required by the Patient Protection/Affordable Care Act, VBP shifts payment models so that hospitals will receive value-based incentive payments which start in October 2013 based on performance or improvement on a set of clinical and patient experience-of-care quality measures. It is now more important than ever to document carefully. Hospital reimbursement will not only be based on severity of illness (case mix) but also on the quality of care delivered and patient outcomes.

What’s at stake for hospitals?

• Hospitals face an expected $270 million in readmission penalties
• Stakes increase each year, as these programs increase the percentage of reimbursement at risk across several years

Hospitals face two choices:  Make sure revenue stays at least neutral during this transition; or, leverage this focus on accurate documentation for payment to improve its overall case mix index – and turn VPB into a strategic advantage. With ICD-10, hospitals have the opportunity to increase specificity by shifting the Medicare Severity Diagnostic Related Group coding system (MS-DRG), explaining resource consumption patterns, and reporting severity of illness, or risk of mortality.

If a hospital is ready to look at VBP as a strategic advantage, then top-level administrators should ask themselves the following:

• Do you have a CDI program in place now—or plan to ASAP?
• Are you actively monitoring your CDI program?
• Are you benchmarking yourself to your peers with a CDI program?
• Have you set goals for targeted improvements?
• Are you reviewing all payment schemes that base payment on coded data?
• Are you prepared to manage the CDI opportunities afforded by both ICD-10-CM and ICD-10-PCS?
• Have you determined if your CDI program is adequate for both ICD-9 and ICD-10 success?

If a hospital answers ‘no’ to any of the above questions, they are leaving opportunities at the door.

Editor’s Note: Melinda Tully, MSN, CCDS, CDIP, at the time of this article's original release, was vice president of clinical services and education. She joined the Nuance team in October 2012 as part of the J. A. Thomas & Associates acquisition. This post originally published on the Nuance blog “For the Health of IT.”