Q&A: Physician education regarding financial impact

October 21, 2021

CDI Strategies - Volume 15, Issue 47

Q: I am hoping you can provide some insight on compliance and ethical provider education related to hierarchical condition category (HCC) risk adjustment. I’ve reviewed the ACDIS Code of Ethics for the development of provider education, but could use additional guidance. Is it ethical and/or compliant to educate providers with printed tools that include a financial impact comparison of specified versus unspecified diagnoses if this education is not tied to any patient or query practices? The ACDIS Code of Ethics says:

“Given the expansion of Medicare Advantage programs and the use of HCC capture in identification of expected financial expenditure for patient care, CDI programs are now focusing on CC/MCC, and HCC capture. […] There is no compliance concern related to this practice. [...] Best practice is to ensure that the long-term plan for a CDI department is to expand from a purely financial focus to overall accuracy of all provider documentation, regardless of whether reimbursement is affected, within the identified departmental and organizational scope. Regardless of the focus of its department, […] CDI staff should participate in the creation of compliant query processes and practices.”

A: This question has popped up in some conversations within the last few days, which means you’re not alone in your concerns. We teach in our Boot Camps that when speaking to the physician about a specific patient, CDI staff should not include any direction/instruction related to what diagnoses will allow for CC/MCC or HCC capture. In general, when speaking to physicians regarding a specific patient and/or encounter, CDI staff should never refer to how specific documentation will affect quality measures, medical necessity, or severity of illness/risk of mortality, either. Discussing this information related to a specific patient record could be construed as a leading and noncompliant practice.

We should simply ask the questions needed for the clarification of the medical record in order to accurately describe the care provided and assign a code that’s as specific to that care as possible.

My mantra when physicians used to ask me, “What is it you want me to document?” was “I want you to document what is right and true to this patient, for this encounter.” Providers also often asked me to tell them which query response was the “right answer” and I would respond, “the right answer is the one you determine to be true based on the care you provided this patient.”

Now, when providing generalized education in newsletter articles, meetings, email blasts, etc. (and NOT speaking to an individual physician about a specific patient) there are times when explaining the financial effect of CDI efforts and physicians’ own documentation helps illustrate the importance of that documentation to both the facility and the physicians’ financial stability. Providers need to have a basic understanding of these concepts, so they can learn the needed specificity to allow code assignment appropriate to the encounter and the patients’ severity of illness.

I often provided my physicians side-by-side comparisons of fictional cases to demonstrate how just a few words or explanations could aid the code assignment and allow communication of the patient’s level of complexity. They don’t need to be experts in reimbursement, quality measure reporting, etc., but they do need to have a basic understanding of how important their documentation is.

Here are some article links you might find helpful:

Editor’s Note: Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, CDI education director at HCPro, answered this question. For information regarding CDI Boot Camps, click here. This article originally ran in February 2019 and has been updated according to all new coding and documentation guidelines.

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