CDI/Coder Agree Rate
One of the many metrics my CDI team is evaluated on is CDI/Coder Agree Rate with the benchmark set at 80%. My team is struggling to meet this benchmark and I am struggling to find any value in this metric. I can see the value of having a discussion with the coder when you don't match (especially when the CDI has a higher DRG or has a completely different DRG for education) but I am struggling with the amount of time making sure you match the exact DRG when the chart is final coded. We consistently achieve 65% agree rate with the coders but this includes cases that have subsequent documentation available (after the CDI looks at the case for the last time) either from subsequent notes or the discharge summary. We are looking at >85% of the admissions to our facility with a 30% query rate. My team is made up of RN's with many years experience both at the bedside and in CDI. Thank you in advance for your opinions and knowledge.
Patty Vitasinski RN CCDS
Supervisor, Henry Ford West Bloomfield Hospital
pvitasi2@hfhs.org
Comments
We don't benchmark this. We do DRG reconciliation for mismatches and I think that's a more valuable use of time. It also incentivizes the CDI's to attempt to 'get it right' because then they have less retro work. But I personally don't want the CDI's spending a ridiculous amount of time getting a working DRG. It's just not my focus.
Katy
1. Effectiveness of post-discharge CDI-Coder communication
2. Missed query opportunities & education
The expectation is that if the Coder arrives at a different DRG than the CDI, they 'ping' the CDI Specialist via the electronic tool. There is a space for notes, such as "pt had xyz procedure after last CDI review, moving the DRG to __" and "DC Summary ruled out abc diagnosis". If these messages are addressed in real time, the codes & DRG can be revised and the 'mismatch' is resolved and counts toward the agree rate.
If the mismatch is due to disagreement about sequencing/principal diagnosis choice or whether a diagnosis is clinically supported, further conversation can occur for educational purposes. If agreement is not reached between CDI and Coding, the case stands as a mismatch to be reviewed by the CDI Lead & Coding Manager.
As in other aspects of life, sometimes we must agree to disagree. : )
Jeanne McCorkle BSN, RN, CCDS
Yes, it does!
Paul
So my predicament today is that my coder coded an MCC that had been documented as ruled out. Although she is to communicate with me if there is a change in MCC's /CC's, primary diagnosis and/or DRG shift, she said she didn't realize it shifted the DRG (it was the only MCC) and it ended up being billed without my knowledge that this occured. These type of situations rarely happen, but maybe 2-3 times over the past 1 1/2 yrs since I started CDI.
Although we have an on-site HIM manager and out-pt coders, our in-pt coding is outsourced. I am never sure what to do with this type of information, I took it to the HIM manager and she told me she wasn't going to "micro manage" the process for me and me and the coder need to to work out our system. I thought she would want to know since if there becomes a denial on this case, she would likely be the one to get it. She said it's too late to do anything about it anyways and I need to "let it go."
Do any of you have a process in place or suggestions on what you would do in this kind of situation?
Thanks!
In these situations, I go directly to the coder (ours are also contracted, off-site). I find that they are generally more than happy to fix and rebill and its easier to deal with them directly. Just double check that they actually sent it to be rebilled ;-).
It is NOT too late to fix it!
Katy
Do you mean that do you not have existing relationships with coders? if not, this is likely something to work on. Over the last few years we have worked with 5+ contract companies and always maintained relationships with the coders on our accounts. We reconciled DRG mismatches and we handle all the retro queries so there isn't really an option but even when we didn't do those things, we still could contact them with questions/concerns (and vice versa). We do work most closely with the coders themselves though. I very rarely have much contact with the HIM director and I do not think she would be very helpful because she is managing a large department, much more than the coders. However, we do have a coding manager. Currently ours is on-site but in the past those were remote as well but they would be the contact if I had issues in dealing with the coders. But I always go directly to the coders first. If you do not have an existing relationship with the coders, I would recommend establishing one. Ask for an email list, introduce yourself and explain your role. CDI and coding really need to work together to be effective.
We don't have anything specific as far as a committee. Currently we do have a monthly educational meeting between both CDI and coding.
You've gotten some great advice from others but I was curious what your normal reconciliation process is. At one of our sites we usually try to have a once a month CDI/Coder collaboration meeting where we try to discuss issues, clinical and coding topics, charts that gave us all headaches (lol), etc..
Thanks,
Jeff
We have regular and weekly meetings. I advocate strongly that there is not an option in regards to the deletion of a code that lacks support. The standard protocol within the coding profession is to rebill and correct such a claim for the sake of data integrity.
Thanks, Paul
If a "coding" error is found, the account is rebilled if within the appropriate time frame but if we have a "missed opportunity" where CDI nor coding picked up on an issue to further clarify by way of a query, that becomes an educational opportunity and is not rebilled. I understand this is due to the fact that rebilling automatically flags an account for review (I am not sure if this is correct).
Valerie Parent
Just as Paul said above, there are times when a re-bill is appropriate and ethical.
proddy@clarionhospital.org, I'm sorry the HIM Director seemingly "blew you off". I suppose she is willing to let it go because when the denial happens, she will plead 'no contest' and the error will correct itself (payment-wise).
Jeanne McCorkle BSN, RN, CCDS
Stanford Healthcare - ValleyCare
We do not currently have any meetings between CDI and anyone, kind of a lonely world, lol. Thanks again for all of your advice and listening to me vent my frustrations.
Have you told the coder? I would just contact eh coder and they would fix the code and contact billing to re-bill.
Katy
There should be someone managing the coding process that understands the case needs to be rebilled. If this work is being performed by a 3rd party, perhaps you'd contract the mgr of the offsite firm. I agree w/ the sentiment this can be a complicated process and such issues will occur; but, there is a means to correct each claim. If the coding mgr won't/can't revise, I'd suggest you record some type of memo for the record to memorialize your efforts to ensure compliant billing.
Paul Evans, RHIA, CCDS, CCS, CCS-P
I am meeting with administration (hopefully this week yet) to ask for better guidance in how they want situations like this handled. I am following my policy and need to know what the next step is.
Jackie Touch