Q&A: Risk adjustment
As part of the fourteenth annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Coral F. Fernandez, RN, CCDS, CCS, system CDI auditor/educator at Baptist Health System in Indiana, answered these questions with contribution from Lori Ganote, MSN, RN, CCDS, system director of clinical documentation integrity at Baptist Health System in Indiana. Fernandez is a member of the ACDIS Furthering Education. Though CDI Week 2024 has now passed (September 16-20), ACDIS wanted to continue highlighting additional expert advice from our committee. For questions about the ACDIS Furthering Education Committee or the Q&A, contact ACDIS Editor Jess Fluegel (jess.fluegel@hcpro.com).
Q: According to CDI Week industry survey data, 46.97% of respondents reported that their CDI team reviews for risk adjustment during their chart reviews in the inpatient setting, while 11.82% do so in both the inpatient and outpatient settings. In what cases does your CDI team review for risk adjustment, and what has been your experience thus far? What challenges and/or successes have you had?
A: We review for risk-adjusted diagnoses for the inpatient setting only and target all admissions for heart failure (HF), chronic obstructive pulmonary disease, pneumonia, sepsis (with pneumonia as secondary diagnosis), coronary artery bypass graft surgery (CABG), arterial ischemic stroke, and acute myocardial infarction (AMI). In recent years, we’ve seen success in the following ways: systemwide standardization of the AMI definition using the Fourth Universal Definition of AMI; the optimization of electronic health record (EHR) to aid in physician documentation of “type I” vs. “type (other)” at the time of heart catheterization completion; and systemwide standardization of HF to include the American Health Association and New York Heart Association descriptions, also optimized in the EHR heart failure pathway. These successes also positively impact CABG and Society of Thoracic Surgeons (STS) scores, as well as the accurate capture of severe sepsis, when applicable, in all sepsis cases regardless of etiology.
We’ve had some challenges extending these efforts across eight facilities. To combat this, we engaged with service lines rather than specific facilities and utilized physician advisors and champions to help facilitate. We also engaged ancillary departments and service line–specific leaders at each facility to promote education.
Q: When asked which risk adjustment methodologies their organization uses, the most popular choice of respondents was CMS-HCCs (48.74%), with the Elixhauser Comorbidity Index and Vizient’s Risk Adjusted Index tied for second place (44.16%). What methodologies does your organization use, and how was that decision made? What advice do you have for a CDI professional wanting to get educated on them?
A: Our CDI team educates using CMS-HCC risk adjusters because [this methodology] is not proprietary and publicly available.
Q: A little less than half of respondents reported that their team tracks their mortality observed-to-expected ratio and/or severity of illness (SOI)/risk of mortality (ROM) impact (49.37%), and the next largest proportion said that they don’t track their risk adjustment impact (25.55%). Does your CDI team track its risk adjustment impact, and if so, how? Do you have any advice for CDI professionals wanting to start tracking their impact?
A: We track our risk adjustment impact utilizing reports provided by our quality leadership, and we validate using CMS data and health services research.
Q: When asked if their CDI program reviews mortalities for risk adjustment and SOI/ROM capture, as well as who on their team was responsible, there was a wide range of answers from all CDI staff to CDI second-level reviewers to team leads/managers. How does your organization handle this, if at all? If so, what challenges and/or successes has your program seen in helping with these reviews?
A: Our second-level reviewers, CDI leads, and the system director of CDI review all quality initiative encounters, mortalities, Patient Safety Indicators, and early elective deliveries.
Q: There are multiple risk adjustment methodologies, including the Elixhauser Comorbidity Index, HHS-HCCs, and Healthcare Effectiveness Data and Information Set (HEDIS) measures. Which does your organization use, and how was that decision made? Can you explain how they differ?
A: We do have Elixhauser built into our coding and CDI software, but our quality leadership relies on an external partner who provides mortality data.
Q: How has your productivity calculation changed when your CDI programs expanded to encompass risk adjustment variables (length of stay and mortality) and other quality-related metrics, in addition to traditional focused reviews?
A: Our goal is to review 3.2 charts per hour, and the majority of the team consistently meets this goal. Second-level review responsibilities fall onto advanced CDI roles with a lower expected productivity rate.