News: OIG Medicare Compliance Review provides new blueprint for CDI reviews

If you haven’t seen the OIG report “Medicare Compliance Review of University of Cincinnati Medical Center [UCMC] for Calendar Years 2010 and 2011,” take a look here at the Office of the Inspector General’s (OIG) website.

What you will see is eye-opening: The OIG reviewed a sample of claims that it deemed were improperly billed by the 695-bed hospital, and, by extrapolating the error rate, determined that UCMC owes more than $9.8 million in improper payments.

The next thing you should consider as a CDI specialist is: How can I prevent my hospital from such a similar (potential) catastrophic review by the OIG? By focusing on affecting positive change in clinical documentation that represents “true” documentation improvement vs. a narrowly defined CDI focus on the capture of CCs/MCCs, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, a manager with Accretive Health in Chicago.

CDI specialists tend to look only at solidifying individual diagnoses in the chart, but often ignore equally important supporting information like clinical indicators to support admission to the facility.

“Do we have good solid documentation of the patient’s DRG, or do we have diagnoses with little clinical support? Are we just sending automatic queries?” he asks. “Often we’re not focused on getting a solid, effective, and encompassing history and physical [H&P] that accurately captures the patient’s history of present illness [HPI] reflective of the patient’s severity of illness, signs and symptoms.”

Physicians tend to elaborate on a patient’s past illnesses vs. a patient’s present illness. A sound HPI consists of a chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present, Krauss notes. “There is often inconsistent or lack of clinical context for the reason for the admission. Doctors need this context for their billing, and [hospitals] need it for quality,” he says.

“Medical necessity is defined and determined by explicit documentation of the clinical information in the chart best representing the need for care provided and ordered by the physician, as opposed to mere diagnoses that CDI specialists traditional seek through the query process,” Krauss adds. “CDI specialists should also focus on physician education and reinforce the need for documentation of key clinical points of the physician’s medical judgment, diagnostic assessment, and plan for each clinical encounter, i.e., the H&P and progress notes.”

Krauss points to p. 4 of the OIG report which identifies 56 errors incorrectly billed as inpatient. These errors are not necessarily incorrectly billed as inpatient, nor are they because the doctor didn’t know how to admit a patient. Rather, it’s because the physician didn’t demonstrate the need to admit the patient, incorporating his/her clinical judgment and medical decision making.

For a good example of what constitutes medical necessity, Krauss offers a recent NGS Medicare presentation on physician E/M billing entitled “Evaluation and Management Services: Part 2.” Slide 19 states, “Supporting criteria for MDM (Medical Decision Making) must move from the mind of the provider onto the page.” This is an important phrase for CDI to keep in mind as they review the chart.

“Each encounter must tell a complete story,” Krauss says. “How do you define quality? You can talk about HealthGrades and other websites, but doctors wonder if all that is simply arbitrary. To me, the real point is efficiency in medicine, moving the patient along the continuum, and providing the rationale for clinical services provided. The record must speak for itself.”

Krauss emphases that MDM is not just the diagnosis, but how the doctor came up with the diagnosis. Labs, ordering the service, abnormal lab values, radiology tests, comorbid conditions, signs and symptoms, etc., are all as vital as the documentation of the diagnosis they support.

“All these things are not difficult fixes. My mantra is we need to acknowledge the deficiencies we have, and then fix them,” Krauss says. “It’s critical for the financial health of your hospital. How can you continue to meet patients’ health needs when you’re giving back $9.8 million?”