Note from a Speaker: A primer on CDI in critical access hospitals

By Jacie Kramer, RN, BSN

The critical access hospital (CAH) was born out of the effort to protect access to healthcare in rural areas and ensure a hospital could remain viable despite the low and variable volumes that come along with the hospital’s location. A CAH is a hospital in a rural area that must meet certain requirements to qualify and be certified as a CAH. To meet these requirements, the CAH must:

• Only have 25 inpatient beds (these beds may also be used for swing-bed, or multi-use, services)
• Be more than a 35-mile drive from any other hospital
• Be more than 15 miles from any other hospital in mountainous areas or access only by secondary roads
• Provide emergency services 24/7
• Have an average length of inpatient stay of 96 hours or less.

If the hospital meets all of the requirements, they are then certified as a CAH and qualify to receive cost-based reimbursement from Medicare. This difference in reimbursement is essential for the survival of these hospitals, but it also creates unique challenges in the development and long-term success of a CDI program.

The general acute care hospital is reimbursed based on the Inpatient Prospective Payment System (IPPS) with all reimbursement essentially generated from the MS-DRGs and coding. Cost-based reimbursement means the CAH is paid at an “interim rate” for all visits at the time of the claim and then is paid a lump sum adjustment after the cost report is filed for the year. With focus often revolving around reimbursement and numbers, and CDI often valued primarily based on this model, the CDI specialist in a CAH definitely has challenges in supporting their value.

When starting the CDI program at Pella Regional Health Center (PRHC), this challenge was certainly present. So, how are we overcoming this difference? First, we learned that some of our payers reimburse based on the APR-DRG system. Therefore, at least for a portion of our population, we are able to show real-time financial impact.

While this was helpful, the vast majority of our population is reimbursed through Medicare, so what can we do to show value here? This is where education was key. PRHC was seen as the “healthiest hospital in Iowa.” While this may sound great, our providers would disagree with this statement due to the aged population we have here with multiple medical comorbidities. How then did PRHC receive this label? Well, the numbers were driven by documentation which created a picture of low severity and low complexity. This is where CDI can have a huge effect. Making sure that the population served by PRHC is accurately reflected by the documentation will create a huge impact on the overall quality reporting.

Additionally, the CAH is still subject to denials and audits, so accurate documentation and diagnosis validation is also paramount in audit and denial protection. The value of improved documentation and charge capture are nearly limitless and this value goes far beyond the real-time financial implications. The true CDI effect is ensuring accurate documentation and reporting. This positive influence can be seen regardless of the reimbursement method of a hospital.

Editor’s note: Kramer and Amy Fletcher, RN, CCDS, will be presenting during the first breakout session on Day 1 of the conference in the Expansion & Innovation track. The title of their presentation is “CDI in a Critical Access Hospital: A Case Study at Pella Regional Health Center.” Their CDI program consists of one inpatient CDI specialist, one outpatient CDI specialist, and a charge master. The program began in early 2017 and has proven incredibly effective in improving documentation and ensuring charge capture in the outpatient population. While the effects of the inpatient CDI program have been significant, the full impact will likely take time and continued persistence. Contact Kramer at jkramer@pellahealth.org. For those interested in connecting with other ACDIS members working in CAH, contact ACDIS Associate Editorial Director Melissa Varnavas (mvarnavas@acdis.org) or Editor Linnea Archibald (larchibald@acdis.org).